THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 


PRESENTED  BY 

PROF.  CHARLES  A.  KOFOID  AND 

MRS.  PRUDENCE  W.  KOFOID 


'^if^'ici^^.,  4  ^ 


y. 


U—i-' 


A 


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LECTUliES 


F  E  V  E  E  S  . 


ALFRED   L.  L00:MIS,  A.M.,   M.D., 

IROFESSOR    OP    PATHOLOGY    AND    PRACTICAL     MEDICINR    IN    THE    MEDICAL     DEPARTMENT    OF    THE 

L'NIVEUSITV  OF  THE  CITY  OF  NEW  YORK  ;    CONSULTING  PHYSICIAN  TO  THE  CHARITY  HOSPITAL 

—TO   THE   BUREAU   OF  OUT-DOOR    RELIEF— lO   THE  NORTH-WESTERN  DISPENSARY— 

TO     THE     CENTRAL     DISPENSARY  :      LATE     VISITING     PHYSICIAN      TO     THE 

BLACKWELL'S   ISLAND   FEVER   HOSPITAL;     VISITING    PHYSICIAN    TO 

BELLEVUE    HOSPITAL— TO    THE    MOUNT    SINAI    HOSPITAL, 

ETC.,    ETC. 


NEW    YORK: 
AV  I  L  L  I  A  >r     ^\'  ()  < »  1 )     it     C  O  M  r  A  N  Y  , 

27  GuEAT  Josns  STurF.r. 
1S77. 


COPTKIGHT,  BY 

WILLIAM    WOOD    &    CO., 

isrr. 


Trow's 

Printing  and  Bookbinding  Co., 

printers  and  bookbinders, 

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NEW   YORK. 


(Jo   tV 
ALUMNI    AND     STUDENTS 

OF  Tiir; 
MEDICAL  DF.rARTMENr  OF  THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK, 

THESE  LECTURES  ARE  DEDICATED 

BY     THEIR     SINCERE      FRIEND, 

THE    AUTHOR. 


ivrT--^o.iP2 


PREFACE. 


These  lectures  were  delivered  in  the  Medical  Department 
of  the  University  of  the  City  of  Xew  York,  to  the  Class  of 
lS7(>-77. 

With  iinimpoitant  alterations,  I  now  olfcr  them  as  they 
were  phonogiaphically  reported  by  Dr.  Wm.  M.  Carpenter. 

As  in  the  preparation  of  my  "Lectures  on  Diseases  of 
the  Lungs,  Heart,  and  Kidneys,"  it  has  been  my  custom, 
after  careful  reading  and  close  analysis  of  the  subject  of 
each  lecture,  to  trust  that  the  stimulus  of  the  class  would 
enable  me  to  present  the  most  recent  views  of  ncknowledged 
authorities,  combined  with  the  results  of  my  own  clinical 
observation  and  experience,  in  so  simple,  intelligible,  and 
concise  a  manner  that  each  student  might  master  the  prom- 
inent points. 

I  have  adopted  an  etiological  basis  in  the  classification 
of  fevers,  and  have  endeavored  to  include  in  a  few  gen- 
eral classes  all  the  numerous  types  described  by  diifinvnt 
writers. 

I  have  referred  to  theoretical  questions  only  so  far  as  was 
necessary  in  oidcr  to  the  projier  understanding  of  subjects 
under  consideration. 

The  Bibliograi)hy  which  accompanies  these  lectures  in- 
cludes those  books,  monographs,  and  theses  which  havn 
been  published  since  I80O,  nearly  nil  of  which  Jiuve  bem 
written,  or  arc  in  circulation,  in  this  country. 

A  few  old  books  have  been  referred  to,  because  they  con- 


Vi  PREFACE. 

tain  many  of  the  so-called  new  tlieories  and  modes  of  treat- 
ing fevers. 

My  aim  has  been  to  give  a  summary  of  the  literature  of 
fevers  in  this  country,  and  so  much  of  foreign  literature 
upon  this  subject  as  might  be  of  interest  and  service  to  the 
student  who  desires  to  thoroughly  investigate  the  subject 
of  fevers.  No  notice  has  been  taken  of  papers  which  have 
only  appeared  in  medical  journals. 

These  lectures  are  the  result  of  careful  stud}^  of  the  litera- 
ture referred  to  in  the  Bibliography,  combined  with  exten- 
sive clinical  experience. 

I  have  endeavored  to  be  unbiassed  in  my  statements  of 
facts. 

It  is  my  purpose  at  some  future  time  to  publish,  in  similar 
form,  lectures  upon  other  infectious  diseases. 

42  West  Twenty -prFTH  Street,  August,  1877. 


CONTENTS. 


LECTURE  I. 

FEA^RS. 


PAOE 

Introduction— Classification— Typhoid  Fever— Morbid  Anatomy 1 

LECTURE  II. 

TYPnorO  FEVER. 
Jlorbid  Anatomy  (continued) — Intestinal  Lesions — Etiology 14 

LECTURE   in. 

TYPHOID  FEVER. 

07 

Symptoms. "' 

LECTURE  IV. 

TTPnoro  FEVER. 

Symptoms  (continued) — DifiEerential  Diagnosis 39 

LECTURE  V. 

TYrnoiD  FE\'ER. 

Prognosis — Duration— Relapses 50 

LECTURE  VI. 

TYPHOID  FEVER. 

Treatment 


61 


LECTURE  VIL 

TYPHOID  FEVER. 
Treatment  (continued) '  ^ 


Vlll  CONTENTS. 

LECTURE  VIII. 

YELLOW  FEVER. 

PAGE 

Morbid  Anatomy — Etiology — Symptoms 85 

LECTURE   IX, 

YELLOW   FEVER. 

Symptoms  (continued) — Differential  Diagnosis — Prognosis — Treatment. ...     95 

LECTURE  X. 

MALARL4.L  FEVERS. 

Introduction 109 

LECTURE  XI. 

SISrPLE   INTERMITTENT   FEVER. 

Morbid  Anatomy — Etiology — Symptoms — Differential  Diagnosis — Prognosis 

—Treatment 119 

LECTURE  XII. 

SniPLE   REMITTENT   FEVER. 

Morbid  Anatomy — Etiology — Symptoms — Differential  Diagnosis — Prognosis.   133 

LECTURE   Xin. 

PERNICIOUS   FEVER. 

Treatment    of   Simple   Remittent   Fever  —  Morbid   Anatomy  —  Etiology — 

Symptoms , 145 

LECTURE  XIV. 

PERNICIOUS  FEVER. 

Symptoms  (continued) — Differential  Diagnosis — Prognosis — Treatment 157 

LECTURE  XV. 

DENGUE   FEVER. 

Morbid  Anatomy — Etiology — Symptoms — Differential  Diagnosis — Treatment 

— Chronic  Malarial  Infection 169 

LECTURE  XVI. 

TYPHO-5IALARIAL  FEVER. 
Introduction — Morbid  Anatomy — Etiology — Symptoms 181 


CONTENTS.  I X 

LECTURE  XVII. 

TYrilO-MAI-AUIAL   FKVER. 

TA'IF. 

Symptoms  (coutinued)— Dillcrential  Diagnosis— Proguosis—Treatment lUO 


LECTURE  XVIII. 

TYPHUS   FKVKU. 

Introduction — Morbid  Anatomy — Etiologj' 205 

LECTURE   XIX. 

TYPHUS  FEVER. 

Symptoms '■^^'^ 

LECTURE  XX. 

TYPUCS  FEVER. 

Symptoms  (continued) — Differential  Diagnosis — Prognosis 229 

LECTURE  XXI. 

TYPHUS   FEVER. 

Treatment 243 

LECTURE   XXII. 

RELAPSING   FEVER. 

Morbid  Anatomy — Etiology — Symptoms — Differential  Diagnosis— Treatment.  256 
LECTURE   XXIIL 

EXANTIIEM.\TOUS  FEVERS. 

Small-Pox — Morbid  Anatomy — Etiology — Symptoms 208 

LECTURE   XXIV. 

SMAI.L-POX. 

Symptoms  (continued) — Differential  Diagnosis— Prognosis 280 

LECTURE  XXV. 

SMALL-POX. 

Treatment  (continued) — Inoculation — Vaccination — Varioloid 293 


X  CONTENTS. 

LECTURE  XXVI. 

SCARLET   FEVER. 

PAGE 

Introduction— Morbid  Anatomy— Etiology— Symptoms 304 

LECTURE  XXVII. 
SCARLET  FEVER. 

Symptoms  (continued)— Complications— Sequelas 315 

LECTURE  XXVIII. 

SCARLET  FEVER. 

Differential  Diagnosis— Prognosis— Treatment 326 

LECTURE  XXIX. 

MEASLES. 

Morbid  Anatomy— Etiology— Symptoms 337 

LECTURE  XXX. 

MEASLES. 

Differential  Diagnosis— Prognosis— Treatment— Roseola— Miliary  Fever 348 


MIASMATIC-CONTAGIOUS 
FEVERS. 


LECTURE   I. 


FEVERS. 


Introduction. — Classification.— Typhoid    Fever.— Morhid 

Anatomy, 

Gentlemen  : — AVe  will  commence  this  course  of  lectures 
with  the  study  of  those  diseases  which  depend  upon  morbid 
conditions  of  the  blood.,  produced  by  morl)ific  agents  de- 
veloped exterior  to  tlie  body  of  tlie  affected.  Such  mor- 
bific agents  may  give  rise,  either  directly  or  indirectly,  to 
morbid  processes  ;  either  by  the  clianges  which  the}"  pro- 
duce in  the  blood,  or  by  their  action  on  the  different  organs 
tiiul  tissues  of  the  body  to  which  they  are  conveyed  by  the 
])l()()d-vessels  and  lynijihatics. 

The  class  of  morbific  agents  which  will  now  especially  en- 
gage our  attention  may  be  included  under  the  general  head 
of  viruses. 

By  the  term  virus  I  mean  a  morbific  substance  which  is 
developed  either  from  animal  or  vegetable  tissues  in  the 
process  of  d(*compositif)n,  or  from  the  excretions  of  diseased 
living  beings.  Many  viruses  are  volatile,  and  may  be  con- 
veyed either  by  air,  by  fiuids,  or  by  solids,  and  when  so 
conveyed  they  become  the  means  by  which  diseases  known 
as  contagious  or  infectious  are  transmitted.  Some  viruses 
are  palpable  poisons,  and  may  be  transmitted  from  the  dis- 
eased to  the  healthy  by  inoculation. 

When  the  virus  which  gives  rise  to  a  disease  has  its  origin 
only  in  a  living  being,  from  whom  it  is  excreted  in  an  active 


2  INTRODUCTION. 

state,  capable  of  conveyance  from  one  person  to  another, 
tlien  the  disease  which  it  produces  is  called  contagious,  and 
the  virus  is  called  a  contagion. 

If  the  morbific  agent  which  has  the  power  of  developing 
disease  has  originated  from  decomposing  organic  matter, 
and  has  been  diffused  through  the  air  or  water,  so  that 
infection  may  have  resulted  without  contact  with  one  al- 
ready diseased,  the  disease  is  called  miasmatic,  and  the 
virus  is  called  a  miasm.  For  instance,  intermittent  fever 
is  a  miasmatic  disease,  while  small-pox  and  measles  are 
contagious  diseases. 

With  our  present  knowledge  of  the  nature  and  origin  of 
viruses,  we  can  make  no  classification,  except  that  which 
is  based  on  their  differences  of  action.  We  speak  of 
typhus,  typhoid,  and  malarial  poisons,  but  these  different 
poisons  have  as  yet  no  known  physical  or  chemical  proper- 
ties by  which  we  are  able  to  distinguish  one  from  another. 
We  can  only  recognize  their  presence  by  the  peculiar  mor- 
bid phenomena  which  each  has  the  power  of  developing  in 
the  animal  economy. 

The  different  diseases  which  are  developed  by  the  morbid 
processes  excited  by  these  different  viruses  are,  at  the  pres- 
ent time,  classed  under  the  head  of  infectious  diseases,  and 
the  influence  of  these  viruses  upon  the  body  is  called  infec- 
tion. It  is  also  important  for  you  to  remember  that  all  of 
those  diseases  which  are  included  under  the  general  head 
of  infectious  diseases  have  their  own  sx^ecific  morbid  pro- 
duct, which  will  produce  these,  and  only  these,  diseases ; 
and  although  these  different  diseases  may  have  very  many 
symptoms  in  common,  and  may  very  closely  resemble  each 
other  in  the  phenomena  which  attend  their  development, 
yet  the  specific  character  of  the  morbific  agent  which  has 
produced  them  stamps  them  as  distinct  diseases.  There  is 
reason  to  believe  that  not  one  of  this  class  is  of  spontaneous 
origin,  but  that  each  depends  on  its  own  specific  poison. 
As  to  the  exact  nature  of  such  a  poison,  and  its  element  of 
power  in  the  production  of  disease,  we  have  no  positive 
knowledge ;  at  the  present  time,  in  regard  to  it,  there  are 
two  prominent  theories. 


TNTKODTC'IFOX.  6 

Tilt'  J/rsf  is  based  upon  clicmU'al  i)r()(.'ossos  ;  tlie  second, 
\\\)on  tlic  iiiultiplk'ation  oL'  liviiii;  oru:anisnis. 

'Y\\Q  chemical  theory  mwrnUun^  tliat  afhT  (Ik^  infectious 
element  has  been  received  into  I  lie  blood  it  acts  as  a  i'er- 
nient,  and  gives  rise  to  certain  morbid  ])rocesses  upon  the 
])rinciple  of  catalysis. 

The  theory  of  organisms:^  or  the  germ  theory,  as  it  is 
called,  maintains  that  the  infectious  poisons  are  living 
organisms,  wliicli.  being  received  into  the  blood,  reprodnce 
themselves  indelinitely,  and  by  their  reproduction  morbid 
processes  are  excited  wliicli  are  characteristic  of  certain 
types  of  disease.  This  is  a  very  seductive  theory,  and  at 
the  x^i'i'sient  time  is  quite  extensively  adopted  by  nu'dical 
theorists,  as  it  so  readily  explains  very  man}^  remarkable 
facts  connected  with  the  development  and  reproduction  of 
the  class  of  diseases  which  are  soon  to  engage  our  atten- 
tion. It  is  readily  understood,  and  there  are  so  many  ani- 
mal poisons  which  a])]iear  to  act  in  this  manner,  that  to  one 
AvliosH  opinions  are  not  based  upon  clinical  ex])erience  and 
actual  contact  with  disease,  the  arguments  in  its  favor  seem 
conclusive. 

According  to  this  theory  all  the  different  forms  of  disease 
included  under  the  head  of  contagious  or  infections  may 
be  reduced  to,  or  embraced  in,  two  classes  : 

First,  infectious  diseases  which  depend  for  their  devel- 
opment upon  a  living  animal  organism.  Second,,  those 
which  depend  for  their  jiroduction  upon  a  living  vegetable 
organism.  Unfortunatel}'  for  this  theor}^  the  special  or- 
ganism of  any  one  of  the  infectious  diseases  has  never  been 
so  plainly  described  by  any  one  competent  observer  that  all 
others  in  the  same  field  of  stndy  could  with  certainty  recog- 
nize it.  The  bacterian  theory,  which  recently  has  so  occu- 
pied the  attention  of  medical  men,  especially  in  German3% 
is  rapidly  being  disproved,  and  consequently  as  ra])idly 
being  abandont.'d.  In  this  country  it  can  scarcely  be  lu-ld 
to  have  ever  gained  a  foothold.  It  seems  to  me  that  one 
who  has  watched  bacterian  dt^'elopment  must  arrive  at  the 
conclusion  that  bacteria  found  in  connection  with  the  de- 
velopment of  disease  are  the  product  and  not  the  cause  of 


4  INTRODUCTIOlsr. 

the  diseased  process ;  certain  it  is  tliat  the  theory  that  there 
exists  distinct   typhoid,  typhus,    and    diphtheritic  living 
germs,  which  are  the  propagating  element  of  these  different 
diseases,  still  lacks  that  proof  which  will  lead  the  practical 
physician  to  adopt  it.     The  question  then  comes  back  to 
us,  what  is  the  real  nature  of   those  morbific  substances 
which,  when  received  into  the  human  organism,  have  the 
power  of  manifesting  phenomena  which  characterize  that 
class  of  disease  which  we  term  infectious?     Every  day's 
experience  must   convince  the  careful  observer  that   each 
one  of  this  class  of  diseases  has  a  distinct  producing  cause 
— that   the   poison   of   typhus   will  not  produce   typhoid 
fever,  neither  will  the  poison  of  measles  develop  scarlatina. 
Although  the  phenomena  which  attend  the  development  of 
these  differing  diseases  may  have  many  points  of  resem- 
blance, yet  each  has  a  distinct  origin,  that  is,  has  its  own 
specific  infection,  which  specific  morbific  substance,  when- 
ever introduced  into  the  animal  economy,  either  through 
the  skin,  respiratory  organs,  or  digestive  surfaces,  interferes 
in  a  greater  or  less  degree  with  the  functions  of  organic 
life.    This  interference  is  caused  either  by  changes  Avhich  it 
produces  in  the  constituents  of  the  blood,  or  in  the  solid 
organs  and  tissues  to  which  it  is  conveyed  by  the  blood- 
vessels and  lymphatics. 

After  reviewing  these  differing  theories  and  giving  careful 
attention  to  the  facts  presented  in  their  support,  we  arrive 
at  this  conclusion — that  the  exact  nature  of  these  morbific 
agents  is  unknown.  We  know  that  they  exist,  from  the  dis- 
eased action  which  they  produce  ;  and  from  the  manner  in 
which  these  diseases  are  propagated  we  decide  that  their 
poisons  are  distinct  from  all  other  poisons,  and  that  each  is 
specific  and  can  reproduce  itself  to  an  unlimited  extent. 
The  germ  theory  best  explains  the  phenomena  of  develop- 
ment. The  chemical  theory  has  decided  claims  on  our 
acceptance ;  but  until  our  explorations  shall  have  been  car- 
ried so  far  as  to  determine,  beyond  question,  what  is  the 
exact  nature  of  several  of  these  poisons,  we  shall  be  com- 
pelled to  call  tliem  unknown  morbific  agents,  governed 
by  certain  fixed  laws  of  development  and  propagation.     At 


IXTIIODI'CTIOX.  O 

the  present  time  investigation  in  this  diivrtion  lias  scarcely 
begun. 

As  we  pass  from  the  general  causation  of  this  group  of 
diseases  to  their  chissiiication,  we  find  ourselves  still  in 
doubt.  The  symptomatic  basis  of  classiJication  of  the 
earlier  writers  gave  place  to  the  more  scientilic  and  compre- 
hensive anatomical  basis  of  classification.  This  for  a  long 
period  has  been  almost  universally  adopted,  yet  now  is 
giving  place  to  the  recent  and  more  definite  etiological  clas- 
silication  of  the  present  day. 

When  these  diseases  are  classified  upon  an  etiological 
basis,  very  naturally  they  divide  themselves  into  three 
classes. 

J^irst.—A.  class  in  which  the  morbific  agent  cannot  be 
developed  exterior  to  a  living  being,  but,  when  developed 
witliin  the  system  of  one  individual,  can  be  transferred  to 
another  through  the  atmosphere.  Such  is  the  case  in  mea- 
sles, small- pox,  and  typhus  fever. 

Second.— We  have  another  class  called  miasmatic  or  ma- 
larial diseases,  in  which  the  morbific  agent  is  developed 
exterior  to  a  physical  organization,  and  cannot  be  conveyed 
from  one  individual  to  another. 

77^ //y7.— There  is  a  class  in  which  the  morbific  agent  is 
developed  within,  and  reproduced  exterior  to  a  physical 
organization.  In  this  class,  the  poison  is  developed  within 
the  body,  but  in  order  that  it  may  be  reproduced  it  must  be 
deposited  in  decomposing  organic  matter  exterior  to  the 
body  ;  it  is  then  rapidly  reproduced,  and  when  received  into 
a  healthy  organism  gives  rise  to  diseased  processes.  It  can- 
not be  directly  conveyed  from  the  sick  to  the  healthy,  but 
only  through  the  excrements  of  th<^  sick,  or  through  de- 
com])Osing  organic  matt(M-  exterior  to  the  body,  with  which 
such  excrements  must  have  been  in  contact.  There  may 
be  all  the  elements  necessaiy  to  its  reproduction,  such 
as  decomposing  animal  and  vegetable  matter,  but  the 
disease  will  not  be  develoi)ed  unless  there  has  been  added 
to  this  decomposing  mass  the  specific  poison  of  tlie  disease. 

The  diseases  thus  developed  have-  been  called  inicsinatic- 
coutaijious,  of  winch  typhoid  fever  is  the  best  example. 


6  CLASSIFICATIOTT   OF  FEVERS. 

All  the  different  forms  of  acute  contagions-miasmatic  or 
miasmatic-contagions  disease  may  be  either  endemic  or  e^yi- 
demic. 

They  are  epidemic  when  they  attack  a  large  number  of 
persons  at  the  same  time  and  in  the  same  manner. 

They  are  endemic  when  they  are  often  repeated  in  the 
same  locality.  If  they  attack  individuals  without  regard 
to  time  and  place,  they  are  called  sporadic. 

With  this  brief  introduction,  we  will  enter  upon  the 
study  of  that  class  of  diseases  which  during  the  present 
century  have  been  included  under  the  general  head  of 
fevers. 

Adopting  an  etiological  basis  of  classification,  I  shall 
divide  fevers  into  three  classes. 

Fb'st.  Contagious  Fevers. — I  shall  include  under  this 
head  all  those  fevers  which  depend  for  tlieir  development 
on  a  specific  morbific  agent,  which  agent  must  originate  in 
an  individual  suffering  from  a  like  specific  disease. 

Second.  Miasmatic  or  Malarial  Fevers. — I  shall  in- 
clude under  this  heading  all  those  fevers  which  depend 
for  their  development  on  a  morbific  agent  developed  exterior 
to  the  body,  and  not  connected  with  any  previously  diseased 
phj^sical  organization. 

Third.  Miasmatic-Contagious  Fevers. — I  shall  include 
under  this  head  those  fevers  which  depend  upon  a  morbific 
agent  developed  exterior  to  the  body  in  animal  and  vege- 
table decompositions,  to  which  has  been  added  the  specific 
poison  of  the  fever  which  has  had  its  origin  in  a  diseased 
physical  organization. 

The  following  is  the  classification  which  I  shall  adopt : 

classification  of  fevers. 


First  Class. — Contagious. 


Typhus  Fever,  Relapsing  Fever, 

Small-Pox,  Scarlet  Fevp:r, 

Measles,  Miliary  Fever. 


CLASSIFICATION   OF   FEVKIIS.  7 

ScconfT  Class. — Malarial. 

SlMPI.K   INTERMITTKNT   FlCVEll,  SIMPLF:   RkMITTENT   FeVEU, 

Peunicious  Fevek,  Dknoue  Fever, 

Typiio-mai.akiai,   Fkveh. 

T/i trd  Class.— Miasinatic-Cuiitaii (Oils. 
Typhoid  Fever,  Yellow  Fevkr. 

Tlio  tliird  class  of  fevers  is  a  connecting  link  between  the 
first  and  second  class. 

In  their  patholoixy  and  clinical  liistories  the  fevers  of  this 
class  have  many  things  in  coiuinon  with  those  of  each  of 
the  other  classes,  as  also  in  their  origin,  natui'e  of  poison, 
etc.  On  this  account,  and  from  the  fact  that  during  tin? 
course  of  every  fever  some  of  the  phenomena  of  t}phoid 
fever  are  presented.  I  shall  iirst  describe  those  fevers  in- 
cluded in  the  third  class,  and  shall  commence  with  tyi)liold 
fewr. 

TYPHOID  FEVER. 

This  is  the  most  universally  prevalent  of  all  fevers.  So 
far  as  we  know,  there  is  no  place  where  it  may  not  be 
develo])ed  and  spread.  It  more  frequfMitly  prevails  in  the 
tem})Hrate  zone  than  in  the  torrid  or  frigid,  but  it  is  ])ossible 
for  it  to  be  developed  in  all  latitudes  and  in  all  countries. 

This  disease,  which  is  essentially  the  same  in  all  countries, 
is  designated  by  dilferent  names.  American  writers  describe 
it  under  the  name  of  typlioid  femr .  The  French  call  it  the 
typlioid  affection,  or  doth inerderia.  English  writers  describe 
the  same  form  of  disease  under  the  head  of  enteric  fecer. 
The  Germans  call  it  abdominal  typhus,  or  gastric  femr.  I 
prefer  the  name  typhoid  fever,  and  will  commence  its  his- 
tory by  describing  its  anatomical  lesions. 

MoKBiD  Anatomy. — As  soon  as  the  disease  is  fully  estab- 
lished a  change  in  the  blood  occurs.  It  becomes  darker  in 
color,  coagulating  imixnfectly,  the  serum  being  imi)erfectly 
separated  from  the  solid  constituents,  and  is  of  an  unnatu- 
rally yellow  color.  The  question  arises — did  these  changes 
take  place  in  the  blood  ]irior  to  the  oc(uirrence  of  the  fever, 
between  the  exposure  and  the  period  of  attack  I     It  is  cer- 


8  TYPHOID    FEYEK. 

tain  that  as  soon  as  the  characteristic  symptoms  of  the  dis- 
ease are  present,  the  diminution  in  the  fibrin  of  the  blood 
is  in  exact  proportion  to  the  severity  of  the  fever,  and  the 
number  of  white  globules  is  increased  in  a  similar  ratio. 

As  a  consequence  of  these  blood  changes,  or  in  connection 
with  them,  a  series  of  changes  takes  place  in  those  organs 
and  tissues  of  the  body  in  which  the  processes  of  waste  and 
rej)air  are  most  rapidly  going  on.  These  changes  are  of  the 
nature  of  parenchymatous  degeneration — the  essential  con- 
stituents of  the  affected  organs  and  tissues  being  involved. 

Similar  parenchymatous  changes  are  met  with  not  only 
in  typhoid  fever,  but  to  a  greater  or  less  extent  are  charac- 
teristic of  other  fevers  and  acute  infectious  diseases. 

Spleen. — The  organ  in  which  parenchymatous  degenera- 
tion occurs  earliest  and  most  extensively  is  the  spleen. 

We  find  this  organ  undergoing  three  distinct  changes. 

First. — It  is  increased  in  size,  sometimes  enormously. 
The  enlargement  commences  soon  after  the  beginning  of 
the  disease,  and  goes  on  rapidly  until  the  third  week,  after 
which  it  ceases,  and  after  a  few  days  the  spleen  begins  to 
diminish  in  size.  If  recovery  takes  place,  by  the  time  it  is 
reached  the  spleen  will  have  returned  to  its  normal  size. 

The  splenic  enlargement  is  apparently  due  to  congestion 
and  to  an  increase  of  normal  elements. 

Second. — As  soon  as  the  spleen  reaches  its  maximum 
size,  its  consistency  becomes  soft ;  this  softening  is  some- 
times so  marked  that,  if  a  post-mortem  be  made  at  the  end 
of  the  third  week,  the  spleen  will  present  the  appearance 
of  a  dark,  jelly-like  mass,  which  is  easily  broken  down. 

Third. — The  organ  becomes  almost  black  in  color,  owing 
to  the  intense  congestion  which  attends  its  enlargement, 
and  to  the  deposit  of  a  brown  pigment  in  its  substance. 

These  changes  in  the  spleen  take  place,  in  a  greater  or 
less  degree,  in  ninety-eight  cases  out  of  every  hundred. 

At  the  post-mortem  of  those  who  have  died  of  typhoid 
fever,  infarctions  are  sometimes  found,  although  there  is 
nothing  peculiar  about  them.  In  rare  instances,  rupture  of 
the  spleen  occurs  without  infarctions. 

LiYER. — Changes  in  the  liver  are  by  no  means  as  common 


MolM'.in    ANATOMY.  9 

as  tliose  in  tlie  s})l('i'ii.  The  liviT  may  bo  foiiiid  presenting 
its  normal  appearance,  or  it  may  be  soft  and  llabby.  When 
soft  and  flabby,  a  microscopic  examination  shows  the  liver 
cells  more  or  less  grannlar  and  fatty,  tiie  nnclei  of  the  oi^lls 
can  no  longer  be  seen,  and  the  degeneration  may  become  so 
extensive  that  the  outline  of  the  hepatic  cells  is  lost,  and 
nothing  but  a  mass  of  grannies  remain. 

Occasionally  there  will  be  found  in  the  liver  of  those  wlio 
have  died  of  typhoid  fever  small  grayish  nodules  situated 
along  the  course  of  the  small  veins ;  these  nodules  consist 
of  lymphoid  cells. 

The  lining  membrane  of  the  gall-bladder  sometimes  pre- 
sents evidences  of  catarrhal  or  diphtheritic  inflammation, 
when  there  has  been  no  evidence  of  its  existence  during 
life  ;  cases  are  recorded  where  it  has  been  found  ulcerated. 

Kidneys. — Degenerative  changes  in  the  kidneys  are  of 
not  infrequent  occurrence  in  the  course  of  typhoid  fever ; 
they  vary  in  extent  with  the  duration  and  severity  of  the 
fever.  When  present,  they  are  more  marked  in  the  cortical 
than  in  the  medullary  portion  of  the  organ.  In  some  cases 
they  are  confined  to  the  epithelial  elements,  while  in  other 
cases  degeneration  of  all  the  anatomical  elements  of  the 
organs  can  be  found.  Such  extensive  changes  are  less  lia- 
ble to  occur  in  typhoid  tlian  in  typhus  fever.  Small  gray 
nodules  similar  to  those  referred  to  as  occurring  in  the  liver 
are  sometimes  found. 

If  the  epithelial  degeneration  of  tli<^  cortical  substance  is 
extensive,  the  cells  finally  break  down  into  a  granular 
detritus,  and  the  cut  surface  assumes  a  yellow  color  and  is 
softer  than  normal.  Infarctions  are  sometimes  met  with  in 
the  kidne3^s  of  those  dying  of  t^'phoid  fever. 

TiKAirr. — The  parenchymatous  changes  which  take  place 
in  the  heart  are  more  marked  than  those  in  any  other  or- 
gan, for  its  anatomical  elements  undergo  waste  and  rejiair 
more  actively  tlian  those  of  any  other  oigan  ;  and  if  faulty 
nutrition  is  an  important  element  in  these  degenerative 
changes,  this  organ  must  become  ver}'  nuirkedly  invi.lv.d. 

In  a  large  proportion  of  cases  it  becomes  soft  and  tial)l)y, 
and  is  of  a  grayish  or  brown  color.    Sometimes  it  is  so  much 


10  TYPHOID    FEVER. 

changed  that  its  tissues  are  easily  broken  down  by  moderate 
pressure  ;  it  loses  its  normal  outline,  and  when  remoA-ed 
from  the  body  the  walls  of  its  cavities  readily  fall  together. 
When  its  muscular  tissue  is  examined  microscopically,  in 
many  instances  it  will  be  found  that  granular  changes, 
affecting  the  ultimate  muscular  fibres,  have  occurred  ;  this 
granular  muscular  degeneration  may  involve  a  large  por- 
tion of  the  organ,  or  it  may  be  confined  to  a  few  muscular 
fibres.  It  may  be  a  general  or  a  localized  parenchymatous 
degeneration.  Occasionally  the  muscular  fibres  are  infil- 
trated with  brown  pigment. 

If,  as  is  sometimes  the  case,  the  heart  retains  its  normal 
outline,  is  friable,  and  its  cut  surface  glistens,  the  muscular 
fibres  will  be  found  to  have  undergone  a  change  which  closely 
resembles  amyloid  degeneration  ;  the  muscular  fibres  will  be 
filled  with  a  material  which  presents  the  same  shining  appear- 
ance as  the  amyloid  substance,  but  on  applying  the  iodine 
test  the  same  reaction  does  not  take  place.  It  is  a  form  of 
degeneration  which  occurs  in  typhoid  fever  and  is  not 
confined  to  the  muscular  tissue  of  the  heart,  but  is  found 
to  a  greater  or  less  extent  in  the  voluntary  muscles  of  the 
body. 

Thrombi  are  sometimes  found  in  the  heart,  and  vegeta- 
tions adhering  to  the  valves  and  chordae  tendinese.  These 
may  give  rise  to  infarctions  in  the  different  organs  of  the 
body.  The  existence  of  the  degenerative  changes  in  the 
heart,  to  which  I  have  referred,  may  be  recognized  during 
the  life  of  the  patient,  for  the  heart  sounds  become  feeble 
according  to  the  extent  of  the  degeneration.  In  some  cases 
the  first  sound  of  the  heart  will  be  absent,  and  it  has  been 
claimed  that  when  this  phenomenon  is  present  the  use  of 
stimulants  in  large  quantities  is  indicated. 

Lungs. — The  lungs  undergo  changes  which  have  received 
the  name  of  splenization.  This  is  a  form  of  pulmonary 
congestion  which  has  received  its  name  from  the  close  re- 
semblance which  the  affected  portion  of  lung  tissue  bears 
1o  the  spleen. 

The  affected  lung  tissue  is  of  a  darker  color  than  normal, 
and  scattered  through  its  substance  will  be  seen  little  red 


:\r()rjuD  anatomy.  11 

or  y(>llowisli  white  points  ;  these  litth;  points  are  scanty 
blood  extravasations. 

Lung  tissue  in  a  condition  oL'  sjilcnization  is  ol'  a  (hnk 
reddish  blue,  brown,  or  black  color  ;  its  consistcMicy  is  liiin.'i 
than  normal,  crei)itates  less  freely,  has  a  more  unifonii, 
homogeneous  ap]iearance  upon  its  cut  surface,  and  is  less 
moist  than  normal  lung  tissue  ;  a  dark  fluid  will  sonit-times 
ooze  from  its  cut  surface,  but  not  as  freely  as  in  hypenemia, 
and  tile  fluid  is  more  watery  in  appearance. 

A  microscopical  examination  of  lung  tissue  in  this  condi- 
tion shows  the  capillary  vessels  filled  with  blood,  and  the 
alveoli  containing  a  variable  number  of  cells.  In  other 
words,  it  is  a  condition  closely  resembling  that  condition 
known  as  static  pneumonia,  but  no  inflammatory  process 
exists  ;  it  is  simply  a  stasis  in  the  capillary  circulation, 
accompanied  by  a  slight  increase  in  the  cell  elements  in  tlie 
alveoli. 

BnoNCiiiAL  Tubes. — You  will  rarely  make  an  autopsy 
u])oii  one  who  has  died  of  ty})hoid  fever,  without  finding 
evidences  of  a  more  or  less  extensive  catarrhal  inflammation 
alYecting  the  bronchial  tubes.  So  constantly  is  catarrhal 
bronchitis  present  in  this  fever,  that  Dr.  Stokes  proposed  to 
call  typhoid  fever  bronchial  typhus.  In  most  cases  this 
catarrh  is  not  extensive,  affecting  only  the  larger  bronchi ; 
it  may,  however,  extend  to  the  smaller  tubes  and  give  i-ise 
to  cai)illary  bronchitis  and  broncho-pneumonia.  Pulmo- 
nary infarctions  are  frequently  found  in  the  lungs  of  those 
who  have  died  of  typhoid  fever.  They  are  sometimes  ipiite 
numerous,  are  usually  of  small  size,  and  vary  in  a]i])earance 
according  to  the  stage  of  tlieir  development.  Wlien  recent 
they  are  of  dark  color,  and  feel  like  consolidated  lung  tis- 
sue;  later,  the  color  changes  to  yellow;  they  may  soften 
and  break  down. 

LaTvYnx. — The  larynx,  as  well  as  the  In-onchial  tubes,  is 
frecpiently  the  seat  of  catarrhal  iiithnniriatiou ;  less  fre- 
quently it  is  the  seat  of  diphtheiitic  inllammati(jn.  in  con- 
nection with  these  laryngeal  inflammations,  ulcers  aji])ear 
in  the  larynx;  these  have  received  the  name  of  "ty])iioid 
ulcers  of  the  larynx;"  sometimes  they  give  rise  to  quite 


12  TYPHOID    FEVEK. 

extensive  hemorrhages.  In  connection  with,  or  independent 
of  these  Uiryngeal  ulcers,  ulceration  of  the  mucous  mem- 
brane of  the  mouth  and  pharynx  may  occur ;  at  times  it 
involves  the  epiglottis  in  such  a  manner  as  to  clixD  off  its 
edges.  These  ulcers  may  develop  on  the  mucous  membrane 
of  the  Eustachian  tube.  In  those  cases  where  permanent 
deafness  follows  an  attack  of  typhoid  fever,  it  will  usually 
be  found  due  to  ulceration  of  the  mucous  membrane  of  the 
Eustachian  tube. 

Beaix  and  Nervous  System. — As  yet  we  have  not  been 
able  to  determine  Avhether  there  are  any  structural  changes 
in  the  brain  or  nervous  system  so  constant  that  the}^  may 
be  regarded  as  lesions  of  typhoid  fever,  although  it  is  rea- 
sonable to  infer  that  in  a  disease  where  such  severe  func- 
tional distui;bances  of  the  cerebro-spinal  system  exist  there 
must  be  constant  and  dehnite  parenchymatous  changes. 
GEdema  of  the  pia  mater  and  of  the  brain  substance,  with 
occasionally  quite  extensive  adhesions  of  the  dura  mater  to 
the  cranium,  not  infrequently  exist.  Punctate  extravasa- 
tions into  brain  substance  are  found  in  a  certain  number  of 
cases,  but  even  in  severe  cases  they  are  not  always  present. 

Stomach. — The  changes  which  occur  in  the  stomach  are 
equall}^  important  with  those  that  occur  in  the  other  inter- 
nal organs,  and  are  degenerative  in  their  nature.  Softening 
and  degeneration  of  its  glandular  structure  is  sometimes  so 
extensive,  that  if  recovery  from  the  fever  takes  place,  a 
very  long  time  must  elapse  before  the  organ  can  perform  its 
normal  function.  It  is  the  existence  of  these  degenerative 
changes  that  gives  rise  to  the  disturbance  in  digestion  which 
is  present  in  so  many  cases,  not  only  during  the  continuance 
of  the  fever,  but  during  convalescence. 

Muscles.— In  addition  to  the  degenerative  changes  which 
I  have  described  as  occurring  in  the  internal  organs  in 
typhoid  fever,  I  must  say  a  word  concerning  those  which 
so  recently  have  been  found  almost  invariably  present 
in  the  voluntary  muscles.  This  muscular  degeneration 
is  of  two  varieties :  First,  a  granular  degeneration,  which 
corresponds  to  ordinary  fatty  degeneration.  Second,  a 
waxy  degeneration,  which  consists  in  the  conversion  of  the 


MOKl'.II)    AXA'IOMV.  13 

contractile  substance  of  tlie  "i)rimiliv(>  buiullcs  into  a  lionio- 
^•(Micous,  waxy  sliiiiiiiu-  mass.  Often  l)o(li  Conns  of  dcuvn- 
eration  occur  (olii'IIu'i-.  soiiiriiincs  one  and  soiiicliuifs  llic 
other  ])ii'(loniinalin_i;-. 

In  both  foi'ins  of  dcLCcncration  tlic  muscular  libivs  brcomc 
lliickcrand  nioi'c  brii  i  ].>  ili.-in  normal.  In  the  liiulicst  dc- 
<i,ret's  of  dcii( 'Herat ion  the  muscular  hbres  are  entirely  lost, 
and  the  muscle  may  jiresent  a  ycllowisli  oi-  whitish  a]i])ear- 
ance,  so  that  hardly  any  traces  of  the  noiwiial  color  of  tli(> 
muscle  remains.  During  convalescence  tlie  noi-mal  I'ed 
color  of  tlie  mnscle  retui'us.  Tliis  muscular  degeneration, 
howevei'.  is  iu)t  })eculiar  to  typhoid  fever,  but  is  met  with 
in  all  severe  infectious  diseases. 

Tlie  want  of  muscular  power,  A\hich  is  so  prominent  a 
sym]itoni  during  the  iKMglit  of  the  fever,  may  depend  on  th(^ 
disturbances  of  the  nervous  system,  but  the  excessive  loss 
of  muscular  power  which  is  so  oft(Mi  ])resent  during  conva- 
lescence is  due  almost  entirely  to  the  muscular  changes. 
The  physical  strength  returns  graduall}^  during  convales- 
cence as  the  muscles  are  reg(3nerated,  and  it  may  be  months 
before  it  is  full}-  re-established.  The  muscles  of  the  tongue 
undtM'go  degeneration  in  the  same  way  as  the  other  vol- 
untary muscles,  which  accounts  in  some  degree  for  the 
interference  with  the  function  of  that  organ  so  often  a 
pronunent  ]ihenomenon  of  the  diseas(\ 

TIk'  soli r a nj  glands  enlarge,  become  lirni  and  tense,  and 
assume  a  more  or  less  brown-yellow  coloi'.  Tiiey  have  the 
consistency  of  cartilage.  Late  in  the  disease  the  hardness 
diminishes,  and  they  assume  a  red  cohu".  These  changes 
are  due  to  a  ]xirenchymatous  degeneration  of  the  glands, 
whicli  has  ])een  preceded  by  a  cellular  liyper})lasia.  It 
accounts  to  a  certain  extent  for  the  diminution  of  tlie 
salivary  secretion,  causing  adryiiess  of  rhe  patient's  mouth. 
which  is  so  marked  and  constant  an  attendant  of  the  fever. 

Similar  cellular  and  ]iarenchymatous  changes  take  ])Iace 
in  the  pancreas. 

Changes  similar  to  these  occur  in  other  febrile  diseases, 
so  that  tiiey  cannot  be  regarded  as  characteristic  of  ty])hoid 
fever. 


LECTURE    II. 


TYPHOID  FEVER. 

MorMd  Anatomy  {continued).— Intestinal  Lesions. — Eti- 
ology. 

At  my  last  lecture  I  completed  the  history  of  those  pa- 
renchymatous changes  which  are  most  frequently  met  with 
in  typhoid  fever.  I  mentioned  that  th&se  changes  could 
not  be  regarded  as  characteristic  of  this  type  of  fever,  for 
they  are  present  in  other  diseases.  By  some  these  degen- 
erations are  regarded  as  the  necessary  result  of  a  pro- 
longed high  temperature,  but  they  are  in  no  way  different 
from  those  degenerations  which  occur  as  the  result  of 
blood-poisoning  where  prolonged  high  temperature  does 
not  occur.  Especially  is  this  the  case  in  those  diseases 
which  are  marked  by  their  malignity  rather  than  by  their 
high  temperature,  as,  for  instance,  acute  yellow  atrophy 
of  the  liver. 

Continuing  the  history  of  the  morbid  anatomy  of  this 
fever,  I  now  come  to  those  changes  which  occur  in  the 
lymphatic  system  of  the  intestinal  track. 

The  Intestinal  Lesions. — These  are  the  most  impor- 
tant pathological  lesions,  and  have  been  called  the  charac- 
teristic lesions  of  the  disease,  as  these  intestinal  changes 
distinguish  this  fever  from  all  other  forms  of  acute  disease. 

As  the  poison  of  small-pox  manifests  itself  by  certain 
changes  in  the  tegumentary  investment  of  the  body,  and 
the  poison  of  epidemic  cerebro- spinal  meningitis  by  the 
formation  of  pus  in  the  meshes  of  the  pia  mater,  so  the  poi- 


Morjun  AXATo.^[Y.  15 

son  of  typhoid  fever  acts  directly  U])oii  tlie  mucous  mem- 
brane of  the  small  intestine,  <2:ivin,<;  rise  to  a  catarrhal 
inflammation  accompanied  by  changes  in  its  anatomical 
structure,  which,  in  the  order  of  their  develojmient,  are 
characteristic  of  the  disease.  The  character  and  extent  of 
these  changes  depend  U])on  the  duration  of  the  fever  and 
their  nearness  to  the  ileo-cjccal  valve;  the  changes  are 
most  markiHl  in  the  patches  nearest  to  the  valve,  and  less 
mark<^d  in  those  farthest  removed  from  the  valve. 

In  drscribing  these  intestinal  lesions,  I  will  suppose  that 
we  are  examining  a  severe,  well-developed  case,  which  runs 
its  regnlar  conrse  withont  complication.  Th(^  changes  can 
be  most  conveniently  studied  by  first  considering  those 
which  occur  within  the  lirst  week  of  the  disease ;  tlLen^ 
those  which  are  developed  within  the  second  week;  next^ 
those  which  are  most  commonly  found  in  the  third  week ; 
and  lastly  those  which  occur  within  the  fourth  week.  They 
appear  to  begin  as  a  catarrhal  inflammation  of  the  mucous 
membrane.  During  the  first  iceek  the  mn(;ons  membrane 
surrounding  the  glands,  especially  that  surrounding  the 
Peyerian  patches,  becomes  hyperjemic  and  swollen  ;  gradu- 
ally the  glands  become  more  and  more  elevated,  their  sur- 
face assumes  a  dark  reddish  color,  interlaced  by  white 
lines;  this  is  known  as  the  '^shaven-heard  appearance.^'' 
These  changes  begin  and  are  most  marked  in  the  glands 
nearest  the  ileo-ca3cal  valve  ;  they  are  generally  well  marked 
within  forty-eight  hours  after  the  commencement  of  the 
disease,  but  are  not  fully  developed  until  the  end  of  the 
iirst  week.  By  the  end  of  the  first  \yeek  all  the  glands  are 
involved  which  are  likely  to  undergo  change. 

In  {\\e  second  iceek,  the  mucous  membrane  of  the  intes- 
tine becomes  less  red;  the  agminated  and  the  solitary 
glands  more  elevated  ;  the  white  lines  upon  their  surface 
disappear,  and  they  assume  a  uniformly  red  color.  An 
unusually  lapid  cell  development  takes  place  in  the  folli- 
cles. By  this  excessive  development  and  tin-  multii»li«-ation 
of  the  cell  elements  of  this  gland  structure,  the  follicles 
become  swollen  in  all  directions.  Usually  the  new  cell 
growth  extends  beyond  the  limit  of  the  follicles,  so  that  the 


16  TYPHOID    FEVER. 

adjoining  mucous  membrane  is  also  infiltrated  with  cells. 
These  newly  formed  cells  may  wander  through  the  muscu- 
lar coat  and  penetrate  the  sub-serous  tissue.  By  the  mid- 
dle or  latter  part  of  the  second  week  the  process  passes 
into  its  second  stage,  and  necrotic  changes  are  established 
in  the  newly  formed  tissue.  These  morbid  changes  may 
terminate  in  two  ways :  first,  the  new  elements  in  these 
ductless  glands  may  become  disintegrated  and  undergo 
absorption,  and  in  this  way  they  may  gradually  undergo 
resolution  ;  second,  individual  follicles  of  the  agminated 
glands  may  rupture  and  discharge  their  contents  into  the 
intestine ;  third,  the  most  frequent  and  characteristic  ter- 
mination of  the  typhoid  process  is  the  separation  of  the 
dead  tissue  as  a  slough,  and  the  formation  of  the  typhoid 
ulcer.  Usually  the  sloughing  and  removal  of  the  necrotic 
tissue  does  not  take  place  until  the  third  week  of  the 
disease.  The  surface  of  the  ulcers  now  presents  a  yellow 
appearance,  simply  because  they  have  been  stained  yellow 
by  the  bile.  As  the  sloughs  gradually  loosen  and  fall  off, 
there  is  a  loss  of  substance  which  extends  to  the  deeper 
layer  of  the  mucous  membrane,  removing  the  entire  gland 
and  the  mucous  tissue  surrounding  it,  laying  bare  the 
muscular  coat  of  the  intestine.  The  necrotic  process  may 
extend  and  involve  the  muscular  tissue  and  end  in  perfora- 
tion of  the  peritoneal  covering. 

The  size  and  form  of  the  ulceration  corresponds  to  that 
of  the  necrotic  tissue ;  if  an  entire  Pej^erian  patch  is 
necrotic,  an  elliptical  ulcer  is  formed,  with  its  long  axis 
corresponding  to  that  of  the  intestine.  In  the  jejunum  and 
large  intestines  the  ulcers  are  usually  small  and  round. 
The  edges  of  the  ulcer  are  sharp,  tumid,  and  overliang  the 
floor  of  the  ulcer.     Sometimes  the  ulcers  are  hemorrhagic. 

In  the  fourth  loeelt  the  process  of  cicatrization  is  com- 
menced. Gradually  the  swollen  edges  of  the  ulcers  sub- 
side, granulation-tissue  springs  up  from  their  base,  con- 
nective-tissue membrane  is  formed,  the  edges  of  the  ulcers 
become  united  at  their  base,  which  is  covered  with  a  layer 
of  epithelium.  The  gland  structure  is  never  regenerated. 
The  cicatrix  which  is  formed  by  the  healing  of  these  ulcers 


MOKr.ID    AXATOMY.  17 

is  slightly  depressed,  and  less  vascular  tliati  the  stnioinid- 
iiig  mucous  membrain'.  hiiiing  rh<'  healing  ])r()!-ess  rli*- 
cicatrix  becomes  more  or  less  ])ignii'nr('d  ;  these  ]>igin«'nt<'d 
scars  may  be  recognized  years  after  the  cicatrization  has 
taken  place.  These  cicati-ices  seldom  cause  any  puckering 
or  diminution  in  the  calibre  of  the  intestine.  In  many 
cases  the  process  of  cicatrization  does  not  pursue  this  regu- 
lar course  ;  while  one  portion  of  the  ulcer  is  cicatrizing,  the 
process  of  ulceration  in  another  part  may  be  extending; 
such  long-confcinued  ulceration  may  prolong  conval'^si-, 'Hcc. 
and  even  cause  death  from  exhaustion. 

I  will  now  briefly  review  these  intestinal  changes,  and  if 
you  will  bear  in  mind  the  weekly  order  in  which  they 
occur,  3'ou  will  better  remember  them. 

The  first  thing  noticed  is  congestion,  which  is  most 
nuirked  around  the  glands  ;  with  this  congestion  the  glands 
become  changed  in  color.  Xext,  the  glands  become  en- 
larged, which  enlargement  is  due  to  a  rapid  development  of 
cells  within  their  structure  ;  these  cells  are  for  the  most 
part  lymi)hoid  ;  but,  in  addition,  there  are  present  large, 
round  cells,  with  several  nuclei.  These  large,  round  cells 
are  formed  not  only  in  the  glands,  but  in  the  mucous  and 
submucous  tissue  adjacent  to  them  ;  consequently,  the 
enlargement  encroaches  more  or  less  upon  the  surrounding 
mucous  membrane.  These  newly  formed  cells  not  only 
swell  the  glands  and  press  upon  each  other,  but  they  press 
upon  the  capillary  vessels  which  furnish  these  structures 
with  nutrition  ;  consequently,  there  is  an  interference  of 
the  circulation  of  the  gland  structure,  and  as  a  result  the 
glands  become  more  or  less  anfemic  ;  degenerative  changes 
occur  as  the  result  of  impaired  nutrition. 

In  some  of  tln^  enlarged  glands  the  new  elements  become 
disintegrated  and  are  absorbed,  and  the  process  ends  in 
resolution ;  in  others,  individual  follicles  soften,  break 
down,  and  their  cont(Mits  are  discharged  into  the  intestinal 
caiud.  and  the  patches  acquire  a  reticulated  appearance. 
>fore  frequently,  a  necrotic  process  is  establislu'd  which 
causes  the  removal  of  the  entire  gland  and  its  contents, 
leaving  an  ulcer  with  everted  and  perhaps  overhanging 
2 


18  TYPHOID    FZVER. 

edges,  with  tlie  muscular  coat  of  tlie  intestine  for  its  base. 
It  is  now  ready  for  tlie  cicatrizing  process,  and  if  it  pro- 
gresses regularly,  first  the  edge  of  the  ulcer  becomes  in- 
verted, then  the  base  of  the  ulcer  is  covered  with  new  connec- 
tive-tissue cells,  the  edges  become  adherent  to  it,  new  con- 
nective-tissue cells  are  thrown  out  upon  the  edges,  and  the 
formation  of  new  tissue  goes  on  increasing  until  finally  the 
process  of  repair  is  complete.  These  ulcers  do  not  always 
run  such  a  regular  course  and  terminate  thus  favorably. 
If  the  nutrition  of  the  glands  and  the  surrounding  tissues  is 
so  interfered  with  that  a  gangrenous  ulceration  is  estab- 
lished, sloughing  follows,  and  the  gland,  with  the  muscular 
and  other  tissues  in  the  neighborhood  of  the  ulcers  which 
are  the  seat  of  cellular  infiltration,  is  removed.  In  some 
instances  the  necrotic  process  continues  to  extend  and  in- 
volves the  peritoneum,  causing  perforation  of  the  intestines 
and  a  fatal  peritonitis.  These  ulcers  may  assume  a  hemor- 
rhagic character,  with  a  surface  of  a  dark  color.  Under 
these  circumstances  they  are  frequently  the  seat  of  profuse 
hemorrhages,  Avhich  may  destroy  the  life  of  the  patient. 
Usually,  when  such  accidents  occur,  vessels  of  considerable 
size  are  involved  in  the  ulcerative  process.  Whenever  the 
sloughing  process  is  arrested,  repair  takes  place  in  the  man- 
ner already  described. 

As  I  have  stated,  these  ulcers  may  be  developed  in  the 
jejunum,  the  ileum,  the  stomach,  and  the  large  intestines. 
In  the  lower  part  of  the  ileum,  at  the  ileo-cjecal  valve,  they 
are  usually  of  large  size — so  large  that  only  small  poi'tions 
of  healthy  mucous  membrane  are  left  between  them  ;  in  the 
jejunum,  stomach,  and  large  intestines  they  are  usually 
round  and  of  small  size. 

Mesenteric  Glands. — Associated  with  these  intestinal 
changes,  analogous  changes  take  place  in  the  mesenteric 
glands.  These  mesenteric  changes  are  also  most  marked  in 
the  glands  situated  nearest  the  ileo-cfecal  valve  ;  they  are 
secondary  to  the  changes  in  the  intestinal  glands,  and  are 
usually  affected  in  a  degree  corresponding  to  the  extent  of 
the  intestinal  lesions.  The  glands  are  first  congested,  then 
there  is  a  production  of  lymphoid  and  large  cells  similar  to 


MolM'.Il)   ANATOMY.  19 

tliose  wliicli  are  found  in  the  enlarged  intestinal  follicles, 
the  glands  become  enlarged,  and  are  the  seat  of  an  acute 
celluhir  hyperplasia.  When  the  enlargement  has  attained 
its  full  size,  tlie  liyjx'raMnia  diminishes,  and  the  cellular 
elements  begin  to  disintegi-ate  and  are  absorbed.  In  al)()ut 
one-half  the  cases  the  enlargement  reaches  its  niaxiimiiu 
size  by  the  middle  of  the  second  or  at  the  commenremeiit 
of  the  third  week.  TIk^  eidarged  glands  vary  in  siz(^  from 
that  of  a  hazelnut  to  a  small  hen's  egg.  In  the  stage  of 
retrogression  some  of  the  glands  simply  shrink  and  return 
to  their  normal  condition;  in  other  ghmds  partial  softening 
takes  place  and  afterwards  absorption,  leaving  a  fibrous 
cicatrix.  If  the  glands  reach  a  very  large  size,  absorption 
is  incomplete,  and  dry,  yellow,  cheesy  masses  are  left,  in 
■which  after  a  time  salts  of  lime  are  deposited  and  they  be- 
come enclosed  in  a  fibrous  capsule.  In  rare  instances  the 
glands  become  fluid,  their  capsules  are  destroyed,  and  the 
softened  masses  escape  into  the  peritoneal  cavity  and  cause 
peritonitis. 

A  calcareous  condition  of  the  mesenteric  glands,  like  the 
pigmented  cicatrices  of  the  solitary  and  agminated  glands, 
give  evidence  of  a  previous  severe  attack  of  typhoid  fever. 
TlK^re  is  yet  another  pathological  lesion  of  typhoid  fever  oc- 
curring during  convalescence,  concerning  which  I  will  speak 
— namely,  a  suppurative  inflammation  in  the  cellular  tissue 
upon  the  surface  of  the  body.  The  inflammation  is  not  of 
an  active  type,  but  is  accompani(^d  by  some  redness  and 
pain  ;  gradually  a  tumor  is  formed  at  the  seat  of  the  inflam- 
mation; usuall}^  this  occurs  where  there  is  the  greatest 
amount  of  jiressure.  After  a  time  fluctuation  becomes  dis- 
tinct, the  swelling  increases  ;  sometimes  two  or  more  of 
these  swellings  coalesce,  and  flnallv  an  immense  abscess 
may  be  formed,  which  when  opened  will  discharge  a  pint  or 
more  of  pus.  These  abscesses  are  due  to  suppurative  in- 
flammation in  the  cellular  tissue  of  the  skin.  Retro-])ha- 
ryngeal  ulcers  are  the  result  of  suppurative  inflnmmntion 
of  the  connective  tissue.  As  a  result  of  imperfect  nutrition 
of  the  skin,  a  gangrenous  inflammation  of  the  skin  may  be 
developed,   which  gives  rise  to   "  bt-d-sores.''  as  tln-y  are 


20  TYPHOID    FEVER. 

commonly  called.  These  are  especially  liable  to  occur  in 
the  hitter  stages  of  a  typhoid  fever  which  has  been  attended 
by  a  prolonged  high  temperature.  The  slough  may  form 
over  the  trochanters,  over  the  sacrum,  or  wherever  the  tis- 
sues have  been  subjected  to  pressure  for  a  long  time,  and  is  a 
consequence  of  impaired  nutrition  of  the  skin.  Sometimes 
this  gangrenous  process  not  only  involves  the  skin,  but  also 
the  subjacent  cellular  tissue  and  the  muscles.  Gangrene  of 
the  toes  and  portions  of  the  integument  which  are  not  sub- 
jected to  pressure  is  due  either  to  thrombosis  or  embolism. 

This  completes  the  history  of  the  anatomical  lesions  of 
typhoid  fever.  In  connection  with  this  history  I  would  call 
your  attention  to  something  of  special  importance,  which  I 
wish  you  would  remember,  namely,  that  typhoid  fever  is  a 
specific  disease  ;  that  it  has  a  specific  pathological  lesion, 
a  catarrhal  inflammation  of  the  intestinal  mucous  mem- 
brane, attended  by  special  follicular  changes  ;  and  though 
you  may  find  present  in  other  diseases  changes  closely  re- 
sembling those  w^liich  I  have  described  as  the  characteristic 
lesion  of  typhoid  fever,  yet  there  is  no  other  disease  in 
w^hicli  these  changes  have  a  regular  development,  in  which 
the  difi'erent  stages  can  be  indicated  with  a  degree  of  cer- 
tainty by  days  and  w-eeks. 

Etiology. — \Ye  very  naturally  pass  from  the  considera- 
tion of  the  mor])id  anatomy  of  typhoid  fever  to  its  etiology. 
According  to  the  classification  of  fevers  which  I  have 
adopted,  it  is  included  in  the  list  of  miasmatic-contagious 
fevers.  Usually,  it  has  been  regarded  as  an  endemic  form 
of  disease.  There  seems  to  be  no  connection  between  its 
development  and  destitution  ;  for  not  only  does  it  choose  its 
victims  from  the  hovels  of  the  poor,  but  from  the  dwellings 
of  the  middle  classes,  and  from  the  palaces  of  the  rich.  It 
ma}^  occur  as  an  isolated  case,  or  w^hole  households  and 
neighborhoods  may  be  stricken  down  with  the  disease.  We 
must  therefore  regard  the  causes  of  its  production  as  local 
and  limited,  and  not  widespread.  It  is  possible  for  it  to 
prevail  as  an  epidemic,  but  it  must  first  have  been  endemic. 

In  studying  the  etiology  of  this  fever,  two  prominent 
questions  present  themselves : 


ETIOLOGY.  21 

F/)\H. — Is  it  a  contagions  form  of  disoasc? 

Seco/id. — Is  it  ever  of  sijontaiieous  origin  i 

The  qnestion  of  contagion  is  one  tliat  lias  been  very 
tlioronglily  discnssed.  For  many  }'ears  representative  med- 
ical men  have  differed  \i\Hm  this  ])oint.  After  years  of 
carefnl  investigation,  I  think  il  may  be  now  nnhesitatingly 
slated  that  facts  do  not  snstain  theo])inioii  that  ty])hoid  fever 
is  ever,  strictl}'  speaking,  a  contagions  disease,  or  tliat  it  is 
ever  directl}^  transmitted  from  one  individual  to  another. 

Persons  sick  with  this  fever  are  now  admitted  into  onr 
general  hospitals,  and  are  placed  in  beds  by  the  side  of 
patients  sick  with  pneumonia  or  any  form  of  chronic  dis- 
ease, without  endangering  the  lives  of  such  patients.  This 
fact  shows  how  generall}^  the  j^rofession  regard  this  disease 
as  non-contagious.  Typhoid  fever  is  no  longer  restricted 
by  quarantine  regulations.  All  these  facts  tend  to  dispose 
of  the  question,  Is  it  a  contagious  disease  ? 

The  question,  Is  typhoid  fever  of  spontaneous  origin  ?  has 
also  been  thoroughl}^  discussed,  and  there  are  strong  advo- 
cates on  both  sides  of  the  question. 

Some  of  those  who  believe  that  it  may  have  a  spontane- 
ous origin  maintain  that  the  poison  which  gives  rise  to  it  is 
developed  b}^  the  decomposition  of  organic  matter,  and  that 
the  specific  character  of  the  fever  is  due  to  the  particular 
substances  which  are  undergoing  decomposition.  Others 
maintain  that  the  decomposing  substance  is  mainly  human 
excrement — in  other  words,  that  decomposing  human  excre- 
ment is  necessary  for  the  production  of  the  peculiar  poison 
which  gives  rise  to  typhoid  fever.  Again,  others  who 
beli<n-e  that  the  disease  is  of  sjiontaneous  origin  maintain 
that  the  presence  of  vegetable  matter  in  certain  conditions 
is  necessary  for  its  production,  and  that  these  conditions 
are  similar  to  those  which  exist  when  miasmatic  fevers  are 
developed,  the  difference  in  the  two  i)oison3  depending 
rather  upon  the  rate  of  temperature  than  ui)on  the  charac- 
ter of  the  ingredients. 

There  is  a  view  only  recentl}'  advanced  in  regard  to  the 
origin  of  tyjihoid  fever,  that  sewer  gas^^s  contain  tiit.'  poison 
which  has  the  power  of  developing  the  disease. 


22  TYPHOID    FEVER. 

On  the  other  hand,  it  is  maintained  by  those  who  do  not 
believe  in  the  spontaneous  origin  of  this  fever  that,  in  addi- 
tion to  decomposing  animal  and  vegetable  matter,  it  is 
necessary  that  the  specific  typhoid  poison  shall  be  incor- 
porated in  the  decomposing  mass.  It  is  the  leaven  (if  you 
choose  so  to  call  it)  which  is  to  leaven  the  whole  mass. 
Dail}^  observation  seems  to  prove  clearly  that  vegetable 
or  animal  decomposition  alone  is  not  sufficient  for  the 
development  of  this  disease,  even  admitting  that  it  depends 
upon  the  decomposition  of  human  excrement.  In  how  few 
of  the  many  dwellings  permeated  with  the  efiluvia  from 
privies  do  the  inmates  have  typhoid  fever. 

Again,  facts  do  not  sustain  the  claim  of  those  who  say 
that  sewer  gases  contain  the  typhoid  poison,  for  those  cities 
in  which  the  sewerage  is  most  inij^eri'ect,  and  those  houses 
most  frequently  permeated  with  sewer  gases,  are  not  the 
hotbeds  of  typhoid  fever.  Again,  this  fever  is  more  preva- 
lent in  tlie  country  than  in  the  city,  in  places  where  there  are 
no  sewer  gases  ;  indeed,  well-marked  cases  of  typhoid  fever 
are  of  quite  rare  occurrence  in  the  city,  and  when  they  do 
occur  seem  to  be  developed  independently  of  defective  sew- 
erage. In  other  words,  all  the  elements  which  favor  its  pro- 
duction may  be  present,  such  as  animal  and  vegetable 
decomposition  or  sewer  gases,  and  yet  not  a  single  case  of 
typhoid  fever  be  developed,  until  some  person  having 
typhoid  fever  comes  within  the  i^recinct,  or  some  substance 
containing  the  typhoid  poison  is  brought  within  the  boun- 
daries favorable  to  its  development  ;  then  a  severe  endemic 
of  the  disease  may  be  developed. 

In  carefully  reviewing  the  history  of  the  origin  of  this 
disease  in  the  different  localities  in  which  for  the  first  time 
it  has  suddenly  appeared  and  prevailed,  we  will  find  that 
the  advent  of  one  suffering  from  the  disease,  or  the  intro- 
duction of  matters  from  such  a  person,  has  been  the  start- 
ing-point of  the  endemic  ;  in  other  words,  that  one  of  these 
two  conditions  is  a  primary  necessity  for  its  production. 

We  therefore  almost  necessarily  reach  the  conclusion  that 
something  is  necessary  for  the  development  of  the  typhoid 
poison  besides  favorable  external  conditions ;  that  animal 


ETIOT.Or.Y.  23 

mid  v(^n:('rablt>  (l('C()ini>()sitioii  docs  not  ])rinuuily  ori.uiiKilt; 
the  poison,  but  lurnislies  a  I'livorablc  soil  for  ils  giowth 
and  dcvcloiinicnt. 

Facts  warrant  us  in  inakini;  tlie  statenicnt  that  while  on 
the  one  hand  tyi)hoid  fever  caiuiot  be  regarded  as  a  strictly 
contanious  disease,  on  the  other  hand  it  is  not  of  spontane- 
ous origin. 

It  is  hardly  necessary  for  nie  to  revimv  all  the  facts  which 
have  a  bearing  ujjou  this  subject.  I  believe  any  uni)reju- 
diced  person  will  arrive  at  this  conclusion  from  tin?  careful 
study  of  them,  that  when  typhoid  fever  makes  its  ap])ear- 
ance  in  any  locality,  its  development  is  preceded  by  the 
introduction  of  a  specific  typhoid  poison,  which  has  been 
re]:)roduced  (in  most  instances)  in  connection  with  decom- 
posing human  excrement. 

The  question  now  arises,  What  is  the  real  nature  of  that 
poison  derived  from  a  person  sick  with  typhoid  fever,  which 
has  the  power  of  indeiinitely  rei)roducing  itself  outside  of 
the  liody  in  connection  with  decomposing  organic  matter, 
and  thus  becomes  the  infecting  agent,  when  individuals  are 
brought  within  its  intluence  ? 

The  history  of  endemics  of  typhoid  fever  leads  to  the  con- 
clusion that  the  poison  is  contained  in  the  fjccal  discharges 
of  the  sick.  When  such  excrement  is  in  a  fresh  condition 
the  poison  is  not  active  ;  it  must  go  through  a  stage  of 
development  outside  of  the  body.  This  may  take  place  in 
the  excrement  itself,  but  it  goes  on  more  raj)idly  and  abun- 
dantly if  the  excrement  is  collected  in  privies  or  in  earth 
that  is  already  saturated  with  oiganic  matter.  In  this  way 
you  can  readily  explain  how  a  lyphoi<I  fever  patient  com- 
ing into  a  locality  previously  free  from  the  disease  can 
establish  there  a  focus  of  infection,  from  which  many  per- 
sons may  become  diseased. 

It  is  evident  that  this  poison  is  not  active  in  its  fresh 
state,  from  the  fact  that  the  disease  is  not  carried  directly 
from  one  individual  to  another — as  attendants,  nurses,  and 
phvsicians  are  no  nu)re  liable  to  the  disease  than  those  who 
are  in  no  way  exposed  to  the  disease  and  live  in  a  healthy 
locality.     Mothers  may  sleep  in  the  same  b."<l  with  children 


24  TYPHOID    FEVER. 

who  are  sick  witli  the  fever  without  contracting  the  disease. 
As  has  already  been  stated,  in  order  that  typhoid  excrement 
shall  become  effective  in  the  transmission  of  the  poison,  it  is 
necessary  that  it  sliould  go  through  a  stage  of  development  in 
connection  with  organic  matter  outside  of  the  body  ;  so  it 
passes  from  the  diseased  individual  to  the  localities  which 
are  favorable  to  its  development,  and  again  from  these  lo- 
calities into  the  human  body. 

It  is  difficult  to  determine  the  period  of  incubation,  or 
length  of  time  the  poison  must  remain  in  the  body  before 
sj^mptoms  of  the  disease  are  manifest.  The  history  of  iso- 
lated cases  would  lead  to  the  conclusion  that  the  period 
varies  from  fourteen  to  twenty  days. 

The  next  question  that  arises  is,  How  does  the  typlioid 
poison  gain  admission  to  the  human  body  1  Undoubtedly 
there  are  two  principal  sources  of  infection,  namely,  the  air 
we  breathe  and  the  water  we  drink.  A  large  number  of 
well-authenticated  histories  have  now  established  the  fact, 
that  this  fever  may  be  developed  by  gases  which  emanate 
from  privies,  sewers,  etc.,  which  have  been  the  receptacle  of 
excrement  from  typhoid  patients,  and  also,  by  drinking 
water  from  springs  and  wells  which  have  become  contami- 
nated by  matters  from  adjoining  privies  and  cesspools.  It  is 
also  now  an  accepted  belief,  or  rather,  is  regarded  as  an 
established  fact,  that  water  remains  contaminated,  though 
far  remote  from  the  point  where  it  came  in  contact  with  a 
defective  sewer  or  water-closet. 

Soil  pipes  and  sewerage  may  be  defective  for  a  long  time, 
perhaps  a  year,  or  even  longer,  and  no  case  of  typhoid  fever 
occur,  when  suddenly  an  endemic  of  typhoid  fever  breaks 
out,  and  caref nl  investigation  shows  that  its  development 
was  preceded  by  the  introduction  of  the  excrement  of  a 
single  individual  sick  with  the  disease. 

It  is  the  belief  of  some  that  milk  can  convey  the  typhoid 
poison,  and  there  is  evidence  in  favor  of  this  opinion  ;  but  I 
think  there  is  stronger  evidence  that  the  water  used  to  di- 
lute the  milk,  and  not  the  milk  itself,  is  the  medium  through 
which  the  poison  is  transmitted. 

This  poison  has  great  vitality.     Typhoid  fever  frequently 


ETIOLOGY.  25 

occurs  in  the  same  locality  year  after  year,  wln-ri  tlie 
suiTounding  conditions  are  favorable  to  its  development. 
Those  conditions  which  favor  its  development  are  more  fre- 
quently ])reseut  in  the  autumn  than  at  an}'  other  season  of  the 
year,  and  for  this  reason  it  has  been  called  Autumnal  fever. 

Usually  it  makes  its  appearance  in  a  locality,  year  after 
year,  at  about  the  same  time ;  case  after  case  is  developed 
until  entire  households  and  neighborhoods  become  its  vic- 
tims. Individuals  who  come  to  care  for  the  sick  may  con- 
tract the  disease,  and  even  persons  who  visit  houses  in  which 
the  disease  is  prevailing  may  afterwards  develop  the  fever, 
contracting  it,  not  from  the  sick,  but  from  the  infected  at- 
mosphere of  the  locality". 

Age  must  be  regarded  as  a  predisposing  cause  of  typhoid 
fever.  It  is  much  more  likely  to  occur  in  young  than  in 
old  persons  ;  it  occurs  most  frequently  between  the  ages  of 
fifteen  and  twenty-five,  and  is  rarely  met  with  in  persons 
over  fifty. 

There  are  also  individual  idiosyncrasies  Which  seem  to 
predispose  to  this  fever.  Some  contract  it  upon  the  slightest 
ex])osure  to  the  influence  of  the  poison,  while  others,  fre- 
quently brought  in  contact  with  it  through  long  endemics, 
esca])e.  Again,  an  individual  may  have  repeated  attacks  of 
typhoid  fever.  I  have  in  mind  a  ph3'sician  who  had  typhoid 
fever  four  times,  the  last  attack  ])roving  fatal.  A  person 
who  has  had  typhus  or  scarlet  fever  is  not  likely  to  have  a 
second  attack,  but  no  such  immunity  follows  an  attack  of 
typhoid  fever.  Whatever  view  we  take  of  the  exact  nature 
of  the  typhoid  poison,  it  has  been  quite  conclusively  de- 
monstrated that  this  poison  differs  very  essentially  from 
that  of  other  fevers. 

From  this  l)rief  review  of  the  etiology  of  this  fever,  we  are 
led  to  the  following  conclusions : 

JPirst.— That  its  develo-[)ment  is  independent  of  over- 
crowding, and  that  it  attacks  the  ricli  and  poor  indiscrimi- 
nately. 

Second. — Tiiat  it  may  l>e  comiiuinicatecl  fi(.iu  one  jierson 
to  another  through  the  excrements  which  have  undergone 
decomposition  after  their  discharge. 


26  TYPHOID    FEVER. 

TJiird. — That  an  endemic  of  typhoid  fever  only  occurs 
where  tlie  air  or  drinking  water  of  the  locality  has  become 
poisoned  by  emanations  from  typhoid  excrements  which 
have  undergone  decomposition,  and  that,  if  the  fever  be- 
comes epidemic,  it  is  a  circumscribed  epidemic,  and  not 
widespread. 

Fourth. — That  the  exact  nature  of  the  typhoid-fever  poi- 
son is  still  unknown. 


LECTURE   III. 


TYPHOID  FEVER. 

S>/m2')toms. 

I  SHALL  this  morning  commence  the  history  of  the  symp- 
toms of  ty})hoid  fever. 

If  I  shouhi  attempt  to  give  you  a  correct  picture  of  this 
disease — one  perfect  in  all  its  colorings — it  would  occu])y 
too  much  time,  and  you  would  become  so  confused  as  to 
be  unable  to  recall  even  the  outline  of  the  picture. 

After  I  have  briefly  spoken  of  the  manner  in  which  this 
disease  makes  its  advent,  I  shall  consider  the  prominent 
symptoms  of  a  typical  case,  and  then  discuss  in  detail  tliese 
symptoms,  wiiliout  special  regard  to  the  time  of  their  oc- 
currence. This  fever  is  usually  insidious  in  its  a])proach, 
and  comes  on  with  a  certain  degree  of  uneasiness  through- 
out the  syst<^m ;  the  patient  feels  uncomfortable,  has  no 
l^ain,  l)ut  feels  that  he  is  about  to  be  sick.  If  the  individual 
is  in  a  region  where  the  disease  is  prevailing,  it  is  quite 
common  to  hear  the  expression,  "I  believe  I  am  going  to 
have  the  fever,"  and  yet  those  who  make  such  complaint 
will  scarcely  admit  that  they  are  sick.  They  coni])lain  of  a 
grumbling  headache,  more  or  less  aching  of  the  liml)s,  "  a 
tired  feeling  all  over,"  chilly  sensations,  alternating  with 
flashes  of  heat ;  loss  of  ai)petite,  and  not  unfrequeiitly  nau- 
sea and  vomiting  are  present.  These  premonitory  symp- 
toms gradually  increasing  in  severity,  by  tlie  fifth  or  sixth 
day  the  i)atient  is  comiK-Ued  to  take  to  his  bed.  At  this 
early  period  there  may  be  a  slight  diarrhcra.  In  very  mild 
cases  the  disease  conies  on  so  insidiously,  and  with  symp- 
toms so  mild,  that  the  patient  is  often  able  to  pursue  his 


28  TYPHOID    FEVER. 

ordinary  avocations,  coinplaining  only  of  an  undefined  in- 
disposition—not feeling  exactly  well,  but  not  regarding 
himself  as  really  sick.  In  very  many  severe  cases  it  is  im- 
possible for  the  patient  to  accurately  fix  upon  the  time 
when  the  fever  commenced.  In  no  case  will  you  be  able  to 
make  an  early  positive  diagnosis.  Typhoid  fever  may  be 
suspected,  but  that  is  as  far  as  you  can  safely  go. 

In  all  cases  variation  in  temperature  is  one  of  the  most 
important  early  symptoms.  Such  variation  in  temperature 
in  a  typical  case  may  be  divided  into  four  periods,  of  one 
week  each,  which  correspond  to  the  four  weeks  of  the 
disease. 

In  the  first  week  there  is  a  gradual  and  steady  rise  in 
temperature,  with  regular  morning  and  evening  variations. 

This  is  one  of  the  characteristic  features  of  the  disease. 
If,  in  any  case  of  fever,  you  find,  while  making  your  ther- 
mometrical  observations,  that  there  is  a  gradual  rise  in  tem- 
perature, marked  during  the  first  week  by  regular  morning 
and  evening  variations,  you  may  be  quite  certain  your 
patient  has  typhoid  fever.  This  gradual  rise  of,  and  these 
variations  in  temperature  are  not  present  in  every  case,  but 
when  they  are  present  they  will  greatly  assist  you  in  mak- 
ing an  early  diagnosis. 

It  has  been  said  that  typhoid  fever  is  the  only  disease, 
except  double  quotidian  intermittent  fever,  that  gives  two 
full  thermometrical  curves  within  twenty-fours  ;  that  is, 
two  full  remissions  and  two  exacerbations.  If  this  is  true, 
it  helps  to  explain  certain  high  temperatures  in  the  morn- 
ing, and  aiTords  valuable  assistance  in  making  a  diagnosis. 

During  the  second  week  the  variations  in  temperature  are 
slight,  retaining,  however,  the  same  degree  of  exacerbation 
which  was  reached  at  the  end  of  the  first  week. 

The  variations  during  the  third  week  are  remittent  in 
character. 

During  the  fourth  week  they  become  intermittent,  and 
the  range  of  temperature  in  the  exacerbations  is  lower. 
The  variations  in  pulse  correspond  to  the  variations  in  tem- 
perature. During  the  first  week  the  pulse  gradually  be- 
comes more  and  more  frequent,  and  remains  at  the  height 


SYMPTOMS.  29 

rraclird  at  the  end  of  tlu'liist  week;  lliroui;liou(  Ihc  second 
and  iliird  weeks  ihci-c  are  distinct  morning-  and  cvcnin^^ 
remissions;  durinu;  the  ronrtli  week  it  falls  to  its  iioinial 
standard. 

On  the  seveiitli  day,  or  sometimes  bctwiM-n  it  and  the 
twelfth  day,  the  characteristic  eruption  iipp(.'ars.  Al)oiit 
this  time  the  licadaclie  al)ates  and  more  or  less  somnolence 
and  delirium  conu'  on.  The  delirium  at  llrst  is  slight,  and 
is  only  obsei'ved  during  the  night.  Day  by  day  the  patient 
loses  liesli  and  strength,  and  becomes  more  and  more  un- 
conscious, and  all  the  phenomena  of  the  typhoid  state  are 
develoi)ed,  viz.,  a  dry  blown  tongue,  feeble  ]uilse,  low  mut- 
tering delirium,  stupor,  tremors,  subsultus,  involuntary 
evacuations,  and  the  other  phenomena  of  great  prostration. 

If  the  disease  is  to  terminate  favorably  the  amendment 
is  usually  gradual.  The  first  sign  of  improvement  is  a  de- 
cided remission  of  the  fever.  During  the  first  week  there 
is  usually  some  diarrhoea  ;  in  very  many  instances  it  is  pres- 
ent before  the  patient  seeks  the  advice  of  the  physician. 
It  may  have  ceased  at  the  time  he  seeks  such  advice. 

Such,  in  brief,  are  the  phenomena  which  attend  the  usher- 
ing-in  and  developing  stage  of  an  ordinary  case  of  typhoid 
fever ;  they  are,  however,  subject  to  numerous  modifica- 
tions. Some  cases  of  this  fever  are  mild  throughout  their 
entire  course  ;  some  are  severe  at  first  and  mild  afterwards ; 
some  are  mild  at  first  and  severe  afterwards ;  while  others 
are  severe  throughout  their  entire  course. 

In  the  detailed  study  of  the  prominent  phenomena  of 
this  disease  I  shall  nt^t  attempt  to  follow  the  order  of  their 
development,  for  they  are  subject  to  so  many  variations 
that  such  a  course  is  imi)Ossible. 

In  ourattem])t  to  analj'ze  its  principal  symptoms  I  will 
first  notice  the  changes  which  take  place  in  the  counte- 
nance. 

TiiK  PiiYsKxiXOMY.— As  a  rule,  in  the  milder  cases,  the 
countenance  has  noj^iing  peculiar  in  its  appearance  ;  tlie 
patient  does  not  even  look  ill.  If  the  disease  is  of  a  severe 
type,  by  the  second  week  the  countenance  assumes  a  char- 
acteristic appearance — there  is  a  pah^  olive,  leaden  look, 


30  TYPHOID    FEVER. 

the  eye  becomes  dull  and  tlie  conjunctiva  congested,  and 
usually  there  is  a  small,  rose-colored  spot  in  the  centre  of 
the  cheeks.  The  face  does  not  assume  the  dark  mahogany 
color,  as  seen  in  typhus,  but  in  the  advanced  stage  of  the 
fever  it  has  more  of  the  hectic  flush  of  phthisis. 

Tongue. — The  tongue  will  also  present  certain  changes. 
From  the  very  outset  it  is  covered  with  a  light,  white  coat, 
but  there  is  nothing  special  in  its  appearance  before  the 
end  of  the  first  week  ;  then  it  may  become  red  upon  its 
sides  and  tips,  and  show  a  slight  disposition  to  dryness  in 
its  centre.  As  the  disease  passes  into  its  second  and  third 
weeks,  the  tongue  becomes  more  heavily  coated,  the  coat- 
ing becomes  brown  and  dry,  and  sordes  collect  upon  the 
teeth  and  sides  of  the  mouth  in  sufficient  quantities  to  form 
crusts.  These  crusts  may  become  thicker  and  more  abun- 
dant as  the  disease  progresses.  At  any  period  in  the 
course  of  the  disease  the  tongue  may  suddenly  clear  off, 
and  present  a  shiny  red  appearance,  "beef-colored,"  as  it 
has  been  called.  The  tongue  and  lips  may  become  dry, 
cracked,  and  fissured.  As  the  sordes  are  removed  from 
the  lips,  tliey  will  often  bleed  ;  and  in  certain  cases,  more 
especially  in  the  severer  forms  of  the  disease,  the  entire 
mouth  and  tongue  may  be  covered  with  dark-colored  in- 
crustations. Such  incrustations  are  seen  early  in  connec- 
tion with  those  cases  where  there  are  extensive  blood- 
changes  :  when  present  tlie}^  are  of  grave  significance. 

As  soon  as  convalescence  is  established  the  changes  in 
the  appearance  of  the  tongue  are  very  marked.  One  of  the 
first  indications  of  convalescence  is  a  moist  condition  of  the 
tongue  about  its  edges ;  gradually  its  entire  surface  be- 
comes moist,  and  by  the  time  convalescence  is  fully  estab- 
lished it  is  restored  to  its  natural  condition.  Gastric  symp 
toms  are  always  more  or  less  prominent — loss  of  appetite  is 
one  of  the  earliest  sjanptoms,  and  nausea  and  vomiting  are 
quite  common  during  the  first  week  of  the  fever.  The 
vomited  matters  usually  consist  of  a  greenish  fluid.  When 
vomiting  comes  on  late  in  the  fever,  it  is  due  either  to  sub- 
acute gastric  catarrh,  or  it  is  symptomatic  of  local  or  gen- 
eral peritonitis.     In  a  large  proportion  of  cases  the  thirst  is 


SYMI'To.NfS.  31 

excossivo.  The  lips  ar<'  parcliod,  and  in  severe  cases  nark 
and  Itli-'d.  In  some  eases  luniori-liage  from  tlie  gnnis 
oeenrs. 

DiAPJiiKKA. — Altli<»n,L;li  nxt  invaiial'ly  present,  it  is  so 
frequent  an  attendant  of  this  fever  tiiat  it  is  considered  one 
of  its  cliaracteristie  symptoms.  It  varies  with  the  severity 
of  tlie  attack,  the  date  of  its  coninjencement,  and  its  dura- 
tion. The  cliaracteristie  typlioid  discharges  are  of  a  yel- 
lowish green  color,  described  in  tlie  books  uTid*n-  the  term 
of  "pea-soup  discharges,"  Sometimes  they  are  of  a  dark 
color,  resembling  coffee-grounds  ;  their  reaction  is  alkaline. 
In  some  cases  diarrhoea  is  present  at  the  very  outset  of  the 
disease,  and  continues  throughout  the  entire  course.  In 
other  cases  it  does  not  appear  until  the  third  week.  The 
second  week  is  the  ordinary  time  for  its  appearance.  When 
the  diarrha?a  appears  late  in  the  course  of  the  disease,  the 
discharges  are  more  copious  than  when  it  appears  earl)^  A 
mild  diarrhoea  throughout  the  entire  course  of  the  fever  is 
a  favorable  rather  than  an  unfavorable  symptom.  In  mild 
cases  diarrhoea  is  sometimes  absent. 

I>rTESTiNAL  Hemorrhage. — Intestinal  hemorrhage  is  not 
an  infrequent  attendant  upon  typhoid  fever.  It  occurs  in 
about  one  in  twenty  cases,  and  varies  in  quantity  from  a 
mere  trace  of  blood  in  the  stools  to  a  profuse  discharge  of 
from  sixteen  to  eighteen  ounces.  The  slight  hemorrhages 
which  sometimes  occur  early  in  the  disease  simply  indicate 
a  hemorrhagic  tendency,  the  same  as  the  epistaxis  which  is 
very  frequently  among  the  early  symptoms.  In  both  in- 
stances tlie  bleeding  comes  from  the  capillaries  of  the 
mucous  membrane.  The  more  profuse  hemorrhages  are 
due  to  the  opening  of  an  artery  in  some  intestinal  ulcer. 
IIemorrhag<^s  due  to  this  cause  may  be  sudden  and  profuse, 
and  may  destroy  the  life  of  the  patient.  The  usual  time 
for  the  occurrence  of  these  profuse  intestinal  hemorrhages 
is  in  the  latter  part  of  the  second  and  during  the  third 
week.  These  hemorrhages  are  usually  ]ireceded  by  a  sudden 
fall  in  temi)erature,  ]ierha]>s  two  or  thiee  degrees;  if  then 
in  a  patient  severely  ill  of  typhoid  fever  a  sudden  fall 
in  temperature   occurs  during  the  second  or   third  week, 


32  TYPHOID    FEVER. 

accompanied  by  extreme  prostration,  it  is  very  conclusive 
evidence  that  intestinal  hemorrage  lias  occurred,  although 
externally  the  hemorrhage  may  not  have  made  its  appear- 
ance. When  intestinal  hemorrhage  occurs  during  the  sec- 
ond or  third  week  it  must  always  be  regarded  as  a  grave 
symptom  ;  yet  it  is  not  necessarily  followed  by  fatal  results. 

The  blood  is  usually  fluid,  rarely  clotted  ;  generally  it 
is  of  a  bright  red  color,  owing  to  the  alkaline  condition  of 
the  intestinal  contents.  Copious  intestinal  hemorrhages 
are  more  frequent  in  severe  cases  that  have  been  attended 
by  profuse  diarrhoea.  In  one  or  two  instances  I  hav^e  had 
patients  die  of  intestinal  hemorrhage  before  any  blood 
had  been  voided  externally.  If  the  patient  survive  a  j)i"0- 
fuse  intestinal  hemorrliage,  there  is  great  danger  of  his 
dying  from  peritonitis.  He  may  die  unexpectedly  by 
syncope  a  number  of  hours  after  a  2:)rofuse  intestinal  hem- 
orrhage. 

Abdominal  xx^in  and  tenderness  are  not  usuall}^  present 
at  the  very  outset  of  tj^phoid  fever  ;  generally,  and  almost 
without  exception  in  the  severer  cases,  by  the  sixth  day  of 
the  disease  some  pain  and  tenderness  will  be  present  in  the 
right  iliac  fossa.  The  pain  and  tenderness  usually  increase 
as  the  disease  progresses,  and  in  the  advanced  stages  it  is 
sometimes  so  marked  that  slight  pressure  over  this  region 
gives  the  patient  great  pain.  While  examining  this  region 
in  order  to  determine  the  presence  or  absence  of  pain  and 
tenderness,  remember  never  to  press  the  surface  with  the 
ends  of  the  fingers,  but  alwa^^s  make  the  examination  with 
the  palm  of  the  hand  ;  while  making  the  pressure  watch 
the  face,  and  frequently  you  will  be  able  to  determine  by 
the  expression  of  countenance  whether  you  are,  or  are  not, 
causing  pain,  long  before  an  audible  complaint  is  made  by 
the  patient. 

It  is  also  important  for  you  to  bear  in  mind  the  possible 
occurrence  of  a  more  severe  abdominal  pain — namely,  that 
pain  arising  from  intestinal  perforation.  The  following  are 
the  characteristic  symptoms  of  this  lesion.  If  in  the  course 
of  a  slight  or  severe  form  of  this  fever,  or  even  when  the 
disease  has  been  latent  and  the  diagnosis  of  typhoid  fever 


SYMrTOM>'.  33 

lias  not  boon  oloar,  tlio  pariont  should  bo  suddt'iily  seized 
witli  diai'ilupa.  ])aiii  in  tlio  abdoiiK'ii,  au:,i;i'avat('d  by  pres- 
sure, porlKi])s  at  lirst  localized  in  tlie  right  iliac  fossa,  but 
soon  extciidint::  over  the  entire  al)doininal  cavity,  attondod 
by  symptoms  of  great  prostration,  a  rapid,  feeble  pulse,  a 
sunken,  anxious  expression  of  countenance,  rapid  tympani- 
tic extension  of  tho  abdomen,  nausea  and  vomiting,  quickly 
followed  by  coldness  and  blueness  of  the  extremities,  and 
the  other  signs  of  sudden  collapse,  you  may  be  almost  cer- 
tain that  ^perforation  of  the  intestines  has  occurred.  I  have 
known  this  accident  to  occur  when  convalescence  was  pro- 
gressing ajiparently  safely  and  satisfactorily.  Few  live 
more  than  thirty-six  hours  after  the  occurrence  of  the  per- 
foration. 

Tiimpanitls  is  another  very  common  symptom  of  typhoid 
fever.  Usually  it  is  not  present  during  the  first  week,  but 
by  the  end  of  the  first  or  the  commencement  of  the  second 
week  a  fullness  of  the  abdomen  will  be  noticed.  As  the 
fever  advances,  sometimes  the  distention  often  becomes  ex- 
treme ;  this  is  due  to  a  collection  of  gas  in  the  large  intes- 
tine, developed  from  some  change  in  the  mucous  membrane, 
the  exact  nature  of  which  we  do  not  fully  understand.  We 
only  know  that  sometimes  the  mucous  membrane  of  this 
intestine  very  rapidly  secretes  gas,  or  allows  it  to  generate, 
and  that  the  intestine  becomes  distended  by  its  accumula- 
tion. When  once  it  is  developed  it  remains  until  convales- 
cence is  fully  established.  It  is  alwaj's  an  important 
diagnostic  sign  of  this  fever.  In  connoction  with  the  devel- 
opment of  the  tympanitis,  whon  firm  pressure  is  nuido  over 
the  right  iliac  fossa,  a  gurgling  sound  is  produced;  but 
gurr/liiiff  in  the  right  iliac  fossa  cannot  by  any  means  be 
'regarded  as  a  positive  symptom  of  ty])hoid  fever,  as  it  may 
occur  in  any  disease  where  there  is  distention  of  the  abdo- 
men due  to  accnmulation  of  gas  in  the  intestines.  In  ty- 
phoid fever,  so  long  as  tho  abdomen  remains  tvm])anitic,  no 
matter  what  the  temperature  and  pulse  of  the  ])atient  may 
be,  he  is  in  more  or  less  danger,  for  it  shows  that  there  are 
intestinal  changes  still  in  progress,  and  that  the  re]»arative 
processes  are  not  complete  ;  this  is  more  especially  the  case 


34  TYPHOID    FEVER. 

wlien  the  tympanitis  has  continued  from  the  active  period 
of  the  disease  into  the  jDeriod  of  convalescence.  Therefore, 
the  presence  of  tympanitis  during  convalescence  is  never  to 
be  lightly  regarded. 

These  are  the  most  important  symptoms  wldch  are  refer- 
able to  the  alimentary  tract,  and  may  be  regarded  as  form- 
ing, in  connection  with  the  temperature  variations,  the 
essential  part  of  the  history  of  this  fever. 

Urine.  —  Extended  and  very  careful  analyses  of  the 
changes  in  the  urine  of  typhoid  fever  patients  have  been 
frequently  made,  without  giving  any  very  practical  results. 

Usually  during  the  first  two  weeks  of  the  fever  the  urine 
is  diminished  in  quantity  ;  after  the  second  week  it  is  in- 
creased. During  the  time  it  is  diminished  in  quantit}^,  its 
color  is  dark  and  its  specific  gravity  is  high  ;  when  it  is  in- 
creased and  convalescence  is  established,  it  becomes  pale, 
and  its  specific  gravity  is  lowered. 

The  amount  of  urea  excreted  daily  throughout  the  active 
period  of  the  fever  is  increased.  The  increase  is  in  propor- 
tion to  the  intensity  of  the  fever,  subject  in  some  degree  to 
the  quantity  and  quality  of  the  food  taken.  It  will  be 
greater  when  large  quantities  of  strong  beef-tea  are  taken, 
than  when  the  diet  consists  of  milk.  So  long  as  the  kid- 
neys are  able  to  eliminate  the  excess  of  urea,  no  harm  re- 
sults ;  but  if  the  quantity  exceeds  their  power  of  elimina- 
tion, or  if  their  function  of  elimination  is  interfered  with, 
uraemic  symptoms  will  be  developed,  such  as  delirium, 
stupor,  and  coma. 

Albumen  in  the  urine  is  only  of  occasional  occurrence  in 
the  course  of  typhoid  fever.  When  present  the  quantity 
usually  is  small,  and  it  is  only  temporarily  present.  It 
rarely  appears  before  the  third  week.  Its  appearance  is 
often  marked  by  the  occurrence  of  cerebral  symptoms. 
Renal  epithelium  and  casts  may  or  may  not  be  present 
with  the  albumen.  The  sjoleen  is  often  much  enlarged,  and 
can  be  felt  through  the  abdominal  wall.  The  enlargement" 
is  greatest  in  persons  under  thirty  years  of  age,  and  during 
the  second  week  of  the  fever. 

Nervous  Phenomena. — The  symptoms  referable  to  the 


SYMI'TOMS.  3.") 

noi'Yons  system  arc  not  so  proiiiincnt  in  t3'])hoi(l  as  in 
typhus  fever;  3'et  tliero  arc  niany  cases  in  which  these 
symptoms  phiy  an  inqiortaiit  ])arl  in  its  liislory. 

One  of  the  luosr  constant  ol"  this  (;lassoi"  syin])toins  is  licad- 
ache.  In  tlie  majority  of  cases  it  is  one  of  tin.'  usli('iiii,L;-iii 
symptoms  of  the  disease.  It  is  present  in  mihl  as  will  as  in 
severe  cases  ;  sometimes  it  is  confined  to  tlie  forelu^ad  and 
temples,  more  often  it  extends  over  tlie  wdiole  head — not 
violent,  but  a  dull,  heavy  pain.  It  usually  increases  in 
severity  until  the  middle  period  of  th(3  disease,  certaiidy 
until  the  close  of  the  tirst  week;  and  generally  associated 
with  it  there  is  intolerance  of  light  and  conjunctival  injec- 
tion, pain  in  the  back  and  limbs,  and  a  general  aching  of 
the  whole  body. 

Somnolence  is  another  nervous  phenomenon  present  to  a 
greater  or  less  degree  in  all  cases.  In  mild  cases  it  does  not 
appear  until  late,  and  usually  is  not  long-continued.  In 
the  severer  cases  it  appears  early  and  continues  until  con- 
valescence begins ;  in  fatal  cases  it  increases  up  to. the  time 
when  the  patient  passes  into  a  state  of  coma.  It  is  often 
interrupted  by  delirium. 

In  children  this  symptom  is  especially  prominent,  and  is 
very  valuable  as  a  means  of  diagnosis.  For  example,  if  a 
child  complains  of  feeling  sick,  without  any  well-defined 
pain,  upon  inquiry  you  find  that  he  has  had  little  or  no 
slee])  for  two  or  three  days  ;  gradually  he  passes  into  a  state 
of  somnolence,  which  at  first  is  slight,  but  soon  it  becomes 
])i-()foiind  :  you  may  infer  that  typhoid  fever  is  about  to 
be  developed. 

Dtlir'nim  is  more  ficcpiently  jnvsent  than  absent  in  ty- 
phoid fever.  The  character  of  the  delirium  varies;  the 
usual  form  is  known  as  the  '' low-muttering ''  deliiiuni. 
This  form  is  rather  characteristic  of  tliis  type  of  fever,  and 
yet  in  very  many  cases  the  (Icliiinm  may  be  violent  in 
character,  and  may  become  maniacal  to  such  an  extent  as 
to  require  physical  restraint.  Not  unfrecpiently  tyjihoid 
fever  patients  attempt  to  jump  out^  of  a  window,  or  to  in- 
jure themselves  or  their  attendants  in  their  endeavors  to 
escape  from  fancied  pursneis  ;  or  rhe}^  are  seized  wiih  the 


36  TYPHOID    FEVER. 

impression  tliat  tlieir  attendants  are  their  personal  enemies, 
or  that  within  themselves  there  is  sometliing  fearful  that 
must  be  destroyed. 

It  is  very  common  for  the  minds  of  this  class  of  patienta 
to  be  occupied  with  those  things  which  engaged  their  atten- 
tion just  prior  to  their  illness.  They  imagine  persons  who 
are  absent  are  about  them,  and  not  unfrequently  call  them 
in  the  most  endearing  tones,  or  denounce  them  with  the 
most  violent  epithets. 

The  delirium  rarely  comes  on  until  the  second  week  of 
the  fever,  and  it  commences  and  is  most  active  at  night. 
After  it  has  once  appeared  it  usually  continues  until  con- 
valescence is  established,  and  generally  disappears  during  a 
sound  sleep  which  attends  the  early  stage  of  convalescence. 
The  maniacal  form  of  delirium  in  typhoid  fever  is  usually 
most  marked  at  night.  During  the  low-muttering  delirium, 
if  the  patient  is  asked  questions,  he  will  generally  answer 
correctly. 

Muscular  Prostratioist  and  Paralysis. — In  all  severe 
cases  of  typhoid  fever  muscular  prostration  is  noticeable 
in  the  early  stages,  and  increases  with  the  progress  of  the 
fever.  It  is  generally  most  marked  during  the  third  week. 
Where  there  is  marked  muscular  paralysis,  the  urine  and 
fseces  are  passed  involuntarily,  there  is  inability  to  protrude 
the  tongue,  and  more  or  less  difficulty  in  deglutition.  These 
symptoms  are  often  attended  with  difficulty  or  inability  to 
articulate  distinctly.  Retention  of  the  urine,  occurring 
early  on  account  of  the  inability  of  the  bladder  to  evacuate 
itself,  is  a  very  unfavorable  symptom  ;  the  same  is  true  of 
involuntary  discharges  from  the  bowels. 

Muscular  Tremors. — Tremors  of  the  hands,  or  tongue, 
or  lips,  are  most  often  met  with  in  young  subjects,  and  in 
those  who  are  addicted  to  the  use  of  spirits.  Severe  tremors, 
unaccompanied  by  much  mental  disturbance,  often  attend 
extensive  intestinal  changes. 

Spasmodic  movements,  such  as  subsultus,  hiccough,  etc., 
are  observed  in  the  advanced  stage  of  severe  cases.  Eigid 
contraction  of  the  muscles  of  the  neck  and  those  of  the 
extremities  are  also  sometimes  present  in  severe  cases. 


SYMPTOMS.  37 

General  convulsions  me  oi"  very  rnre  oecnrreneo,  except 
in  very  young  children,  and  when  they  occur  liave  no  spe- 
cial signiiicanco. 

Special  Skxsks. — The  syini)lonis  reTeral)!*'  to  the  special 
senses  require  little  more  than  enumeration. 

As  regards  the  sense  of  s'ufhf,  there  is  notliiiig  wortliy  oC 
note,  except  that  the  eye  assumes  a  dull  expression  and 
that  the  pupil  is  dilated  ;  some  jiatients  complain  of  hazi- 
ness of  vision,  which  is  increased  when  they  assume  a  sitting 
posture. 

The  sense  of  hearing  is  always  more  or  less  impaired  ; 
this  is  most  marked  about  the  middle  period  of  the  fever ; 
then  it  is  impossible  for  your  patient  to  hear  ordinary  con- 
versation— you  will  be  obliged  almost  to  shout  in  his  ear. 

Hinging  and  buzzing  sounds  in  the  ears  are  often  com- 
plained of  in  the  early  stage  of  the  fever. 

When  the  loss  of  hearing  is  confined  to  one  ear,  it  is 
generall}^  caused  by  ulceration  of  the  mucous  lining  of  the 
Eustachian  tube,  or  by  suppuration  of  the  middle  ear. 

The  se)ise  of  taste  usually  is  altered  or  perverted  ;  articles 
of  food  are  tasteless,  or  have  an  unnatural  flavor.  AVhen 
the  tongue  and  mouth  are  covered  with  a  heavy  coating  of 
sordes,  with  a  tremulous  tongue,  the  patient  is  unable  to 
distinguish  between  bitter  and  sweet,  and  swallows  the  most 
disgusting  doses  without  complaint. 

Ill/prrcpsthesia  is  another  disturbance  of  a  special  sense. 
The  surface  of  the  body  of  a  typhoid  fever  patient  may 
become  so  sensitive  that  lie  will  cry  out  with  pain  from  the 
slightest  touch.  Tliis  hy})ei-avsthesia  may  be  present  during 
the  lirst  week,  or  may  not  be  i)i-esent  until  convalescence  is 
established.  It  is  most  marked  over  the  abdomen  and  lower 
extremities,  and  usually  occurs  in  females  of  a  hysterical 
tendency.  It  is  of  importance  that  you  discriminate  between 
cutaneous  tenderness  in  the  abdominal  region,  and  the  ten- 
derness of  i)eritoneal  inflammation. 

ErisTAXis. — I  have  already  referred  to  this  symjttom  as 
of  common  occurrence  in  the  early  stage  of  typhoid  fever. 
AVhen  it  occuis  during  the  first  week,  in  most  cases  it  is  of 
little  importance,  except  as  a  diagnostic  sign  of  this  type  of 


38  TYPHOID    FEVER, 

fever;  when  it  occurs  during  the  third  week,  it  becomes 
important  as  an  element  of  prognosis,  as  it  may  be  suffi- 
ciently profuse  to  destroy  the  life  of  the  patient.  Occurring 
late  in  the  disease,  unless  it  can  be  promptly  arrested,  it 
always  jeopardizes  the  life  of  the  patient. 

Emaciation  is  perhaps  more  marked  and  rapid  in  this 
than  in  any  other  form  of  fever.  It  commences  early  and 
is  progressive.  By  the  time  a  patient  has  reached  the  fourth 
week  of  a  typhoid  fever  of  even  moderate  severity,  he  is 
usually  in  a  condition  of  extreme  emaciation.  In  this  par- 
ticular he  markedly  differs  from  a  patient  ill  vdth  typhus 
fever,  for  in  the  latter  case  emaciation  to  any  great  extent 
does  not  occur. 


LECTURE    IV. 


TYPHOID  FEVER. 

Si/nipfoms  {continued).  — Differential  Diagnosis. 

I  WILL  continue  the  history  of  typhoid  lever,  and  de- 
scribe more  in  detail  those  'cariations  in  temperature  which 
ntteiid  its  development  and  mark  its  progress.  As  has  al- 
read}'  been  stated,  the  temperature  at  the  commencement 
of  a  typical  case  of  this  fever  is  characterized  by  morning 
remissions  and  evening  exacerbations  ;  and  by  these  regular 
variations  often  you  will  be  able  to  make  a  diagnosis  dur- 
ing the  first  week  of  the  disease.  In  order  to  estimate  the 
real  value  of  these  variations,  it  will  be  found  convenient  to 
divide  the  fever  into  four  periods  which  shall  correspond  to 
the  four  weeks  of  the  disease. 

In  making  your  therm ometrical  observation,  in  this  as 
well  as  in  all  othtn-  forms  of  fever,  the  thermometei  may  be 
phiced  in  tlie  axillji?,  the  mouth,  or  tlie  rectum.  You  must 
remember,  however,  that  tlie  temperature  ranges  al)<)ut  one 
degree  higher  in  the  mouth  and  rectum  than  in  the  axilhe. 
I  shall  refer  to  axilhuy  temperatuiv  whenever  I  speak  of 
temperatui-e  without  qualilication. 

Usualh'  the  tem])ei'ature  begins  to  rise  about  noon  on  the 
first  day  of  the  development  of  the  fever,  and  continues  so 
to  do  until  between  six  and  eiuht  o'clock  in  the  evening:, 
when  it  reaches  its  niaximurii  height  for  that  day;  then 
there  is  no  change  until  midnight,  when  it  begins  to  decline, 
and  by  six  or  eight  o'clock  in  the  morning  it  has  reached 
its  minimum  decline,  which  is  a  degi-e<^  higher  than  on  the 
morning  of  the  preceding  day.  After  six  or  eight  o'clock  in 
the  morning  the  temperature  does  not  vary  much   until 


40  TYPHOID    FEVEK. 

noon  ;  then  it  again  begins  to  rise,  and  b}^  six  o'clock  in 
the  evening  it  has  reached  its  maximum  elevation  for  that 
day,  which  is  two  degrees  higher  than  on  the  evening  of  the 
preceding  day.  Again,  at  midnight  it  begins  to  fall,  and  by 
morning  it  has  fallen  a  degree,  Avhich  leaves  the  maximum 
temperature  for  the  day  a  degree  higher  than  on  the  preced- 
ing day.  Thus  it  rises  a  degree  each  day,  with  regular 
morning  and  evening  variations,  until  the  eighth  day  of  the 
fever,  when,  in  most  cases,  it  has  reached  its  maximum 
height.  During  the  second  week  the  temperature  remains 
at  about  the  same  maximum  degree  which  it  has  reached  by 
the  end  of  the  first  Aveek.  There  are  morning  and  evening- 
variations  of  a  degree  or  more,  but  the  maximum  of  the 
evening  exacerbation  remains  the  same. 

During  the  third  week  the  remission  becomes  more  and 
more  marked,  and  with  it  the  temperature  falls,  while  dur- 
ing the  exacerbation  the  temperature  retains  the  same  stand- 
ard as  during  the  second  week.  By  the  end  of  the  third 
week  the  morning  temperature  during  the  remission  will 
have  fallen  two  or  three  degrees  below  the  point  which  it 
had  reached  during  the  second  week. 

By  the  time  fha fourth  loeeJc  is  reached,  or  at  least  by  the 
middle  of  the  week,  the  temperature  becomes  intermittent, 
and  with  each  exacerbation  it  falls  lower  and  lower,  until 
by  the  end  of  the  week  the  normal  standard  of  temperature 
has  been  reached  —  it  may  fall  a  little  below  the  normal 
standard. 

These  are  called  the  typical  therm ometrical  variations  of 
typhoid  fever,  3^et  they  are  not  always  present ;  besides, 
there  are  many  things  which  will  materially  modify  them. 
For  instance,  marked  deviations  from  the  record  may  be 
produced  b}^  complications  Avliich  would  never  have  been 
discovered  but  for  the  irregular  thermometrical  variations. 
By  treatment,  for  a  time  the  temperature  can  be  very  much 
lowered  ;  but,  if  the  treatment  be  discontinued,  it  will  again 
rise.  In  some  cases  you  will  be  unable  to  ascertain  the 
cause  of  the  irregularity. 

Pulse. — The  pulse  is  also  subject  to  variations,  which 
correspond  very  nearly  with  the  variations  in  temperature, 


RYMI'TOMS.  41 

tiiid  occur  not  011I3'  oil  diircicnt  days,  but  at  dill'ci-ciit  hours 
on  the  same  day.  Durini;-  tlie  ilrst  week  I  lie  |iuls(,'  Ix'coiufis 
iHoicaiid  iiioie  frequent,  (111 liim-  (In' second  and  third  weeks 
it  remains  at  its  liei^-lit,  and  during  the  fourtli  we(?k  siidvS 
to  its  normal  average.  During  the  whoh^  course  of  thi;  dis- 
ease it  is  k^ss  frequent  in  the  morning  Ihaii  in  I  he  cvciiing. 

If,  at  the  commencement  of  the  fever,  tiie  pulse  is  ninety- 
eiglit,  it  gradually  increases  in  frequency,  until,  by  the  end 
of  the  lirst  week,  it  has  reached  one  liundred,  oronelinn- 
dred  aiul  ten  per  minute  ;  during  the  second  week  it  remains 
at  about  this  height ;  after  that  time  it  may  run  as  high  as 
one  hundred  and  twenty  or  one  hundred  and  forty.  Dur- 
ing the  first  and  second  weeks  the  rate  of  the  pulse  and  the 
temperature  range  correspond,  but  after  this  time  tiu^  i)ar- 
allelism  ceases,  the  failure  of  heart-i)o\ver  beginning  to 
manifest  itself.  This  failure  of  heart-])ower  is  indicated  by 
ail  increase'  in  the  freqiieiicj^  and  feebleness  of  the  pulse, 
which  at  this  rime  may  reach  one  liundred  and  forty  per 
minute,  and  yet  the  tem])erature  show  no  alarming  varia- 
tion. A  jDulse  which  remains  for  live  or  six  consecutive 
days  above  one  hundred  and  twenty  per  minute  is  a  bad 
omen,  for  it  shows  extensive  changes  in  the  muscular  tissue 
of  the  heart.  Under  these  circumstances,  the  pulse  may 
become  in-egular  and  intermitting.  Should  these  irregu- 
larities and  intermissions  occur  during  the  third  week,  in 
most  cases  they  are  followed  by  death.  With  an  irregular 
and  intermitting  i^ulse,  usually,  you  will  lind  the  first  sound 
of  the  heart  inaudible  over  the  precordial  si)ace,  and  this 
indicates  that  prompt  and  judicious  means  must  be  em- 
ployed to  restore,  if  possible,  the  heart's  normal  action, 
and  thus  relieve  your  patient  and  avert  a  fatal  issue. 

The  severity  of  the  fever  during  the  lirst  and  second 
weeks  of  its  development  is,  to  a  great  extent,  detf'rmined 
by  the  frequency  of  the  ])ulse  and  the  lieight  of  the  tem- 
perature. Although  delirium  and  extensive  tympanitis  are 
important  symptoms,  yet  they  do  not  determine  the  result ; 
but  if  your  patient,  during  tin?  lirst,  or  at  the  commence- 
ment of  the  second  week  of  the  disease,  has  a  pulse  of  one 
hundred  and  twenty  per  minute,  and  a  temperature  of  one 


42  TYPHOID    FEVEK. 

hundred  and  six,  it  is  very  doubtful  whetlier  convalescence 
can  ever  be  established. 

You  must  remember  that  from  feeble  heart-power  alone 
the  pulse  may  increase  in  frequency,  while  the  temperature 
is  steadily  falling.  On  the  other  hand,  the  pulse  sometimes 
falls  almost  to  a  normal  standard,  while  the  temperature  re- 
mains high.  In  either  case,  if  these  changes  occur  during 
the  second  or  third  week  of  the  fever,  they  must  be  re- 
garded with  susjoicion. 

Eruption. — We  now  come  to  the  study  of  what  is  known 
as  the  "  characteristic  symptom  "  of  typhoid  fever,  namely, 
the  eruption.  Some  have  claimed  that  the  eruption  should 
be  considered  as  a  lesion  of  the  disease,  but  I  prefer  to  class 
it  among  the  symptoms.  It  makes  its  appearance  between 
the  sixth  and  twelfth  days,  dating  from  the  commencement 
of  the  fever  (not  from  the  day  the  patient  takes  his  bed,  but 
from  the  time  the  first  symptoms  of  the  disease  manifest 
themselves),  and  it  is  not  attended  by  any  unusual  sensa- 
tion. 

It  remains  visible  from  eight  to  fourteen  days,  leaving  no 
stain  or  mark  on  the  surface  after  its  disappearance.  It 
consists  of  isolated,  lenticular  spots  scattered  more  or  less 
abundantly  over  the  surface  of  any  part  of  the  body,  yet 
usually  most  abundant  upon  the  chest  and  abdomen.  There 
may  be  only  a  few  spots  visible  at  a  time,  or  it  may  be  so 
profuse  as  to  cover  the  body  like  a  rash.  Two  or  three 
well-defined  spots  of  the  eruption  are  sufficient  to  establish 
the  existence  of  the  fever.  Each  spot  is  circular  in  shape, 
and  varies  in  diameter  from  a  point  to  a  line  and  a  half, 
rarely  reaching  two  lines.  It  is  slightly  elevated  above  the 
surface  of  the  surrounding  cuticle,  is  of  a  bright  rose  color, 
disappears  upon  slight  pressure,  and  returns  as  soon  as  the 
pressure  is  removed.  Each  spot  remains  visible  for  three 
days,  and  then  disappears.  Sometimes,  as  one  crop  of  the 
eruption  disappears  another  is  developed,  and  this  may  go 
on  for  eight,  twelve,  or  fourteen  days.  There  are  many 
cases  in  which  only  one  crop  appears.  As  soon  as  one  spot 
makes  its  appearance,  it  is  well  to  mark  it  with  tincture  of 
iodine  or  nitrate  of  silver,  so  that  you  may  be  certain  that 


SYMPTOMS.  43 

your  observations  are  always  madf  upon  tlie  one  point.  If 
it  is  a  spot  of  typhoid  erui)tion,  and  one  croj)  of  (nuption  is 
to  follow  another,  it  will  disappear  within  three  days  from 
the  time  at  whirh  it  was  Hrst  sei-n,  and  other  spots  will  tak<' 
its  place.  It  is  this  feature  which  distinguishes  the  typhoid 
eruption  from  that  of  all  other  fevers. 

The  question  may  be  asked,  Is  this  eruption  essential  to 
the  diagnosis  of  typhoid  fever  ^  Doubtless  there  is  no 
question  in  connection  with  its  history  which  has  given 
rise  to  more  discussion  than  this.  As  a  matter  of  course, 
this  question  has  two  sides.  Many  observers  mention  that 
the  eruption  is  not  constant,  and  consequently  not  neces- 
sary for  its  diagnosis  ;  while  others,  equally  competent, 
maintain  that,  unless  the  eruption  be  present  at  some 
period  during  the  progress  of  the  disease,  the  diagnosis  of 
typhoid  fever  cannot  be  made  with  positiveness.  Jenner 
states  that  he  found  the  eruption  present  in  one  hundred 
and  forty-eight  out  of  one  hundred  and  lifty-two  cases.  I 
would  not  say  that  it  is  possible  for  typhoid  fever  to  occur 
without  the  eruption,  neither  would  I  affirm  that  scarlet 
fever  ever  exists  without  the  characteristic  rash  of  the  dis- 
ease ;  but  I  do  say  that,  as  regards  these  respective  fevei-s, 
that  if  no  eruption  was  present,  I  would  make  the  diagnosis 
with  equal  hesitanc}'  in  the  one  case  as  in  the  other. 

The  eruption  is  usually  most  marked  in  cases  of  typhoid 
fever  which  occur  between  the  ages  of  ten  and  thirty.  Be- 
fore ten  and  after  thirty  years  it  is  usually  not  as  well 
marked,  and  may  be  readily  overlooked  unless  careful 
search  is  made. 

I  have  described  to  you  the  prominent  symptoms  which 
are  present  during  the  course  of  a  ty]ti(al  case  of  typhoid 
fever,  and  believe  you  will  now  l)e  able  to  recognize  the 
disease  and  to  manage  intelligently  your  tyi)hoid  fever 
patients. 

At  this  point  let  me  state  to  you  that  the  tyi)hoid  poison, 
in  its  operation  on  the  human  body,  does  not  always  effect 
the  series  of  changes  and  symptoms  which  I  have  been 
describing.  On  the  contrary,  there  are  cases  which  run  so 
mild  a  course  that  they  can  scarcely  be  dignilied  l)y  the 


44  TYPHOID    FEVER. 

name  of  fever;  besides,  there  are  imperfectly  developed 
cases  wliicli  show  a  great  diversity  in  their  course,  but  they 
all  can  be  included  under  two  heads  : 

First. — Mild  typlioid  fever,  in  which  the  symptoms  are 
all  mild. 

Second. — Abortim  typlioid  fever,  in  which  the  duration 
of  the  disease  is  markedly  shortened, 

Tn  the  tnild  type.,  the  fever  runs  its  regular  course,  but 
it  is  of  low  grade.  The  temperature  rises  regularly  until 
its  maximum  is  reached,  which  rarely  exceeds  103°  F. ; 
then  it  remains  stationary  for  a  time,  generally  about  a 
week  ;  then  a  decline  follows  in  the  same  manner  as  was 
noticed  in  the  typical  case.  This  is  the  regular  course  of 
these  cases  if  left  to  themselves,  and,  as  a  rule,  they  should 
be  left  to  themselves.  Some  of  these  cases  are  so  mild  that 
the  patients  are  not  confined  to  the  bed,  nor  even  to  their 
rooms,  and  perhaps  throughout  the  entire  course  of  the 
disease  are  able  to  transact  a  certain  amount  of  business. 
Such  cases  have  been  called  "walking  cases"  of  typhoid 
fever. 

The  eruption  appears  in  these  cases  early,  is  of  short 
duration,  only  a  few  spots  appear  ;  usually  there  is  only 
one  crop.  Diarrhoea  is  also  present  in  most  cases  of  this 
class,  but  it  is  of  a  mild  type,  the  discharges  from  the 
bowels  apparently  giving  relief  to  the  patient.  In  some 
cases  the  diarrhoea  alternates  with  constipation,  or  consti- 
pation may  be  present  throughout  the  entire  course  of  the 
disease,  and  the  cases  go  on  exhibiting  a  varying  amount  of 
fever  for  from  twenty  to  thirty  days,  until  gradually  conva- 
lescence is  established.  This  class  of  cases,  if  properly 
managed,  rarely  prove  fatal ;  but,  if  improperly  managed, 
there  is  great  danger.  For  instance,  if  a  patient  walks 
about  while  he  is  suffering  from  one  of  these  so-called  mild 
attacks  of  typhoid  fever,  he  does  it  at  great  risk  to  life— in 
other  words,  there  should  be  no  "walking  cases"  of  ty- 
phoid fever.  A  patient  sick  with  typhoid  fever,  however 
mild  the  type,  should  take  to  his  bed  and  remain  there 
until  convalescence  is  fully  established,  as  it  is  impossible 
to  say  just  how  extensive  the  changes  may  be  that  have 


DIFFEKEXTIAL   DIAGNOSIS.  45 

occiirivd  in  tlie  intestinal  track,  and  in  tlio  niiklGst  ty]w  of 
the  disease  tliey  may  be  of  such  a  iiarurc  tliat  very  little 
]>liysical  exertion  will  cause  intestinal  i)eif()ration,  \v]ii<-li 
will  be  followed  by  a  fatal  peritonitis. 

The  ahortiveform  of  tf/pJioid  fever  is  ushered  in  with  all 
the  symptoms  of  a  typical  case — headache,  lassitude,  pain 
in  the  limbs,  nausea,  etc. — and  the  temperature  during  the 
first  week  follows  the  regular  variations  of  the  fever.  At 
the  onset  the  disease  has  every  ap})earance  of  a  severe  form 
of  typhoid  fever  ;  the  temperature  may  rise  as  high  as 
105'  F.  or  106°  F.  by  the  end  of  the  first  wwk ;  delirium  is 
often  active,  and  diarrhoja  is  present.  By  the  end  of  the 
second  week,  certainly  by  its  close,  if  recovery  occurs,  tlie 
fever  is  cut  short,  and  a])ruptly  disappears ;  the  temperature 
falls  to  the  normal  standard,  and  the  patient  passes  on  to  a 
state  of  rapid  and  complete  convalescence.  The  eruption, 
diarrhea,  and  all  the  urgent  symptoms  of  the  disease  may 
be  present,  and  yet  before  the  end  of  the  second  w^eek  the 
patient  may  have  fully  convalesced.  That  it  is  the  typhoid 
poison  which  thus  acts  upon  the  system,  and  gives  rise 
to  the  characteristic  symptoms  of  typhoid  fever  in  these 
abortive  cases,  is  evidenced  by  the  fact  that  at  the  post- 
mortem examinations  the  characteristic  typhoid  intestinal 
lesions  are  found,  and  these,  taken  in  connection  with 
the  presence  during  life  of  the  t^^phoid  eruption,  estab- 
lish the  diagnosis  beyond  question.  There  can  be  no 
doubt  but  tliat  an  individual  may  be  affected,  over- 
whelmed, as  it  were,  by  typhoid  poison,  and  yet  not  de- 
velop well-marked  typhoid  fever.  So,  if  only  a  moderate 
amount  of  tj'phoid  poison  is  introduced  into  the  sj'stem,  a 
mild  or  an  abortive  type  of  fever  will  be  developed.  The 
natural  powers  of  the  individual  to  resist  the  action  of 
such  poisons  must  always  be  regarded,  and  should  be 
taken  into  consideration  in  the  treatment  of  a  case. 

Differential  Diagnosis.— In  a  typical  case,  after  the 
fever  is  fully  developed,  the  diagnosis  is  not  difficult.  Tlie 
presence  of  febrile  excitement,  marked  by  evening  exacerba- 
tions and  morning  rtMuissions,  headache,  diarrhoea,  abdomi- 
nal tenderness,  and  other  abdominal  symj)toms,  and   the 


46  TYPHOID    FETER. 

])resence  of  the  cliaracteristic  rose-colored  spots,  are  snf- 
ticient  for  a  diagnosis. 

In  tlie  mild  type  of  the  disease,  or  when  the  symptoms 
are  developed  irregularly,  or  during  tlie  first  week  of  a 
typical  case,  the  diagnosis  is  often  difficult,  and  sometimes 
impossible.  The  principal  diseases  which  are  liable  to  be 
confounded  with  tj^Dlioid  fever  are  typhus  and  relapsing 
fevers,  typho-malarial  fever,  acute  tuberculosis,  pj^semia, 
septicaemia,  pneumonia,  and  gastro-enteritis. 

The  points  of  differential  diagnosis  between  typhoid  and 
typhus,  relapsing  and  typho-malarial  fevers,  will  be  more 
apparent,  and  more  readily  comprehended,  after  we  have 
studied  these  different  forms  of  fever.  I  shall  therefore  not 
call  3^our  attention  to  their  differential  diagnosis  until  I 
have  given  you  a  history  of  these  fevers. 

Acute  Tuberculosis. — This  disease  is  attended  by  very 
many  of  the  symptoms  which  are  present  in,  and  by  some 
supposed  to  be  characteristic  of  typhoid  fever.  The  fever 
of  acute  tuberculosis  is  of  a  remittent  type,  attended  by 
evening  exacerbations  and  morning  remissions,  delirium, 
a  dry,  brown  tongue,  a  tendency  to  stupor,  great  prostra- 
tion, rapid  emaciation,  and  sometimes  by  a  diarrhoea,  with 
abdominal  tenderness  and  tympanitis.  All  of  these  are 
among  the  prominent  symptoms  of  typhoid  fever  ;  conse- 
quently these  two  diseases  are  frequently  mistaken  the  one 
for  the  other.  More  than  once  have  patients  in  Bellevue 
Hospital,  with  the  diagnosis  of  typhoid  fever,  presented  at 
the  post-mortem  examination  the  characteristic  lesions  of 
acute  tuberculosis.  If,  therefore,  patients  with  acute  tu- 
berculosis may  go  through  a  large  general  hospital,  under 
the  observation  of  diagnosticians,  who  certainly  are  not 
men  of  inferior  ability,  and  be  supposed  to  have  t^^phoid 
fever,  there  evidently  is  great  danger  of  a  mistake  in  diag- 
nosis. 

The  higher  range  of  temperature  in  acute  tuberculosis 
than  in  typhoid  fever  is  one  of  the  distinguishing  character- 
istics of  the  disease.  Usually,  early  in  the  progress  of  the 
disease,  it  reaches  106°  F.  or  107°  F.,  while  in  typhoid  fever 
the  temperature  rarely  reaches  106°  F.,  and  even  then  in 


PIFFEPwENTIAI.    I)IA(;XOSIS.  47 

most  rases  not  Ix-fon-  the  end  of  the  st-coiul  week  of  tlio 
fever,  by  Avliich  linn'  you  will  have  been  able  to  cleter- 
minc^  tlie  true  nature  of  the  disease.  Again,  you  will 
notice  that  there  is  no  eruption,  neither  is  there  enlarge- 
ment of  the  spleen  in  acute  tuberculosis,  while  both  are 
very  constant  attendants  of  ty]»hoid  fever ;  yet  their 
absence  is  not  positive  proof  tliat  typhoid  fever  does  not 
exist. 

In  all  doubtful  cases  you  must  take  into  account  the 
family  history  of  the  patient,  his  immediate  surroundings, 
whether  typhoid  fever  is  prevailing  at  the  time,  and  whether 
the  patient  has  been  exposed  to  tjjihoid  poison.  These 
are  important  points,  and  by  a  careful  study  of  them,  if 
yon  are  able  to  watch  the  case  thronghout  its  entire  course, 
probably  you  will  arrive  at  a  correct  diagnosis  before  the 
end  is  reached.  Should  3'ou  see  the  case  during  the  first 
week  of  the  disease,  rely  upon  the  presence  of  the  rose- 
colored  spots  for  a  diagnosis  of  typhoid  fever,  and  you  will 
rarely  mistake  it  for  acute  tuberculosis. 

Pv-EMi-V  AXD  Septicemia.— These  diseases,  while  devel- 
oping, present  many  S3^mptoms  which  resemble  those  of 
the  developing  stage  of  tyjihoid  fever.  In  most  cases  you 
will  be  able  readily  to  recognize  them,  as  the  surface  of  the 
body  has  a  jaundiced  hu«'  ;  there  are  no  lenticular  spots, 
and  the  febrile  symptoms  are  irregular  in  their  develop- 
ment. There  are  exacerbations  and  remissions,  but  their 
appearance  and  disappearance  are  not  marked  by  any  reg- 
ularity, and  usually  there  is  more  tlian  one  exaciM-bation 
and  remission  in  the  twenty-four  hours.  Not  only  are  the 
variations  in  temperature  irregular,  but  the  temperature 
reaches  a  high  degree  much  sooner,  and  ranges  higher 
throughout  its  entire  course  in  py;i^mia  and  septicaMuia 
than  in  typhoid  fever.  In  pyjcmia  and  septicaemia  you 
will  also  have  early  in  the  disease  profuse  sweatings,  great 
prostration,  rapid  emaciation,  delirium,  subsultus,  tympani- 
tis, and  diarrha?a,  while  in  typhoid  fever  these  do  not  come 
on  until  late  in  the  disease.  Besides,  the  history  which 
precedes  and  attends  the  development  of  jiyaMuia  and  sep- 
ticaemia widely  differs  from  that  of  typhoid  fever. 


f 


48  TYPHOID    FEVEF.. 

There  is  a  condition  of  septic  poisoning  occnsionall}"  met 
with,  resulting  from  the  introduction  into  the  system  of 
septic  malaria  through  the  drinking  water,  which  so  closely 
resembles  that  Avhich  is  the  result  of  typhoid  poisoning 
that  it  is  almost  impossible  to  make  a  dLfferential  diagnosis. 
In  these  cases  the  absence  of  the  rose-colored  spots  is  almost 
the  only  distinguishing  feature. 

Pjs^eumoxia. — Pneumonia,  with  typhoid  symptoms,  is 
sometimes  mistaken  for  typhoid  fever.  It  is  called  in  your 
books  typliokl  pneumonia.  The  differential  diagnosis  is  not 
difScult  if  you  remember  that  the  pneumonia  which  com- 
plicates typhoid  fever  does  not  come  on  until  late  in  the 
fever,  and  you  have  the  regular  history  of  typhoid  fever 
preceding  its  development.  On  the  other  hand,  when  the 
tj^phoid  symptoms  are  present  from  the  beginning  of,  or 
come  on  at  the  end  of  the  second  stage  of  the  pneumonia, 
the  ph^^sical  signs  of  the  pneumonia  will  attend  or  precede 
the  typhoid  symptoms.  There  will  be  cough  and  the  char- 
acteristic j)neumonic  expectoration  ;  there  will  be  no  erup- 
tion, and  no  typical  variation  in  temperature. 

If  you  do  not  see  a  patient  who  is  over  sixty  years  of 
age  with  this  type  of  pneumonia  until  the  second  or  third 
week  of  its  progress,  although  evidences  of  lung  consolida- 
tion may  be  present  frequentl}^,  it  will  be  very  difficult  to 
decide  whether  the  pneumonia  is  or  is  not  complicating 
a  typhoid  fever,  and  under  these  circumstances  of  course 
the  differential  diagnosis  will  be  very  difficult. 

Gastro-enteritis. — In  the  adult  this  disease  is  quite 
readily  distinguished  from  typhoid  fever,  as  the  diarrhoea 
and  vomiting  precede  the  febrile  movement ;  the  fever  is  ir- 
regular in  its  development  and  progress,  and  the  tempera- 
ture rarely  rises  higher  than  103°  F.  In  a  child  between 
two  and  six  years  of  age  it  is  very  difficult  to  distinguish 
gastro-enteritis,  or  intestinal  catarrh,  as  it  is  sometimes 
called,  from  typhoid  fever.  The  eruption  is  not  so  promi- 
nent or  constant  a  S3anptom  in  the  child  as  in  the  adult, 
and  with  both  diseases  we  have  diarrhoea,  tympanitis,  and 
typhoid  symptoms.  These  circumstances  render  many 
cases  of  this  character  difficult  of   diagnosis.     When  all 


TMKFKrj-.NTIAL    DIAGNOSIS.  49 

the  sjniptoms  precede  the  fever,  niid  you  ran  liave  a  liis- 
tory  of  tlie  case,  and  a  tlierinoinetrical  recoi-d  from  the  he- 
iriiiiiiiii:  of  the  fever,  ill  most  cases  you  can  i-eadily  make 
tlie  diaixiiosis  ;  hut  if  you  do  not  see  the  case  until  it  lias 
reached  the  second  week  of  its  pro^rn'ss,  and  you  have  no 
accurate  or  r.'lial»le  history  of  its  development,  a  positive 
diauiiosis  is  impossible. 

'ruiniixoi'S  DisK.vsK. — Poisoning  l>y  trichina'  has  fre- 
quently been  mistaken  for  typlioid  fever.  This  condition  is 
not  unfrequently  attended  Ity  diarrhcpa,  vomitinir,  and  the 
development  of  other  typhoid  sj-mptoms  ;  but  with  poison- 
ing by  trichinje  there  is  almost  constantly  present  muscular 
pains  and  (pdema  of  the  eyelids,  which  will  be  sufficient  to 
arrest  your  attention.  We  have,  then,  in  poisoning  by 
trichina?,  diarrhcBa,  vomiting,  tympanitis,  rapid  emaciation, 
great  exhaustion,  a  brown,  dry  tongue,  higli  temperature, 
and  other  typhoid  sym2)toms  ;  with  these  you  have  the 
oedema  of  the  face,  especially  of  the  eyelids,  and  the  most 
intense  muscular  pains.  By  removing  a  small  portion  of 
the  muscular  tissue  and  placing  it  under  the  microscope. 
the  trichinje  can  be  seen,  and  thus  you  will  be  enabled  to 
make  a  positive  diagnosis. 
4 


LECTURE  V. 


TYPHOID  FEVER. 

Prognosis. — Duration. — Relapses. 

I  HAVE  already  spoken  to  yon  of  tlie  differential  diagnosis 
of  typlioid  fever,  and  will  now  give  3^on  some  of  the  more 
prominent  rules  which  should  govern  you  in  its  prognosis. 

Peognosis. — Death  may  occur  at  any  stage  of  this  fever. 
A  typhoid  patient  is  not  out  of  danger  until  all  tympanitis, 
diarrhoea,  and  other  abdominal  symptoms  which  indicate 
that  intestinal  changes  are  still  progressing,  have  disap- 
peared. Independent  of  complications  the  duration,  type, 
and  intensity  of  the  febrile  excitement  has  more  to  do  than 
all  the  other  elements  in  determining  the  prognosis  in  any 
case  of  typhoid  fever.  The  height  of  the  temperature  on  the 
eighth  day  determines  the  range  of  temperature  that  may 
be  expected  on  each  succeeding  day.  If  upon  that  day  it 
is  not  higher  than  104°  F.  or  105°  F.,  and  has  been  regular 
in  its  development  (independent  of  complications),  the  prog- 
nosis is  good  ;  in  uncomplicated  cases  it  very  rarely  rises 
higher  than  the  degree  it  has  reached  at  that  time.  A  pro- 
longed high  temperature  (above  105°  F. )  after  the  first  week 
renders  the  prognosis  unfavorable. 

In  mild  cases,  during  the  second  week,  a  marked  morning 
remission  occurs,  which  begins  early  and  continues  until 
midday  ;  the  evening  exacerbation  is  late,  and  by  the  end 
of  the  second  week  there  is  a  marked  and  permanent  fall  in 
the  temperature.  In  severe  cases,  the  opposite  conditions 
are  observed.  A  sudden  rise  in  temperature,  or  a  rapid  and 
extreme  fall  at  any  period  of  the  fever,  is  a  very  bad  omen  ; 


niooxosis.  51 

the  latter  ofton  pivrrdt's  tln'  occurrcnro  of  a  soverc  intfstiiial 
hi'inoiiliagc.  ^^larkril  variation  from  the  typical  ti'm])('ra- 
tiire  of  the  diseast'  indicates  the  existence  of  c()in]ilii  atioiis. 
Sliii'ht  decline,  acc()nii>anicd  by  great  fluctuation  of  t<'iii])t'ra- 
ture.  during  the  third  week,  is  an  unfavorable  symptom. 
The  natural  power  of  an  individual  to  resist  disease,  especi- 
ally the  effects  of  iirolonged  high  temperature,  is  a  very 
important  element  in  prognosis.  The  organ  which  is  the 
surest  indicator  of  such  power  (especially  in  t3^phoid  fever) 
is  the  heart.  If  the  pulse  is  full  and  regular,  ])erhaps  beat- 
ing at  the  rate  of  110  or  115  per  minute,  if  the  cardiac  im- 
pulse is  good,  and  a  distinct  first  sound  can  be  heard,  even 
though  at  the  end  of  the  second  week  the  temperature 
stands  as  high  as  106°  F.,  the  prognosis  is  favorable.  If, 
however,  the  pulse  has  risen  to  120  or  130  per  minute,  if  the 
apex-beat  is  feeble  or  imperceptible,  and  the  first  sound  of 
the  heart  is  indistinct  or  altogether  obscured,  with  a  ten- 
dency to  cj^anosis  and  pulmonary  oedema,  the  indications 
are  that  the  patient's  powers  of  resistance  are  failing,  and 
under  such  circumstances  the  prognosis  must  be  unfavor- 
able. It  is  not  so  much  the  rapidity  as  the  regularity,  a 
sudden  falling  and  a  sudden  rising  of  the  pulse,  that  indi- 
cates the  impending  danger.  The  rapid  rising  of  the  pulse 
upon  the  slightest  excitement  is  the  most  unfavorable  indi- 
cation, as  it  shows  extensive  heart-failure  and  a  rapid  giving 
way  of  vital  ])ower. 

A  sudden  fall  of  the  pulse  from  any  cause  must  always 
be  regarded  as  an  unfavorable  indication.  The  abundance 
or  color  of  the  eruption  does  not  influence  the  prognosis. 
Excessive  tympanitis  and  severe  abdominal  pains  are  un- 
favorable symptoms. 

Severe  and  protracted  muscular  tremors,  with  subsultns, 
indicate  danger.  Sudden  collapse  during  the  second  and 
third  weeks  of  the  fever  is  always  attended  with  dang<»r,  as 
it  is  very  likely  to  be  due  to  copious  intestinal  hemorrhages 
or  intestinal  perforation.  It  sometimes  occurs  indepen- 
dently of  either  of  these  causes,  but  nevertheless  is  very  apt 
to  be  soon  followed  by  a  fatal  result. 

The  prognosis  is  alwaj's  bad  in  persons  who  are  very  fat. 


52  TYPHOID    FEVER. 

and  in  those  who  are  the  subjects  of  gout,  diseases  of  the 
kidney,  or  any  otlier  severe  form  of  chronic  disease.  In  all 
such  persons,  duiing  the  second  and  third  weeks  of  the  dis- 
ease, you  must  constantly  be  on  the  watch  for  the  occur- 
rence of  sudden  collapse. 

Different  opinions  have  been  given  as  to  the  importance 
of  intestinal  hemorrhage  in  reference  to  prognosis.  Some 
have  regarded  slight  intestinal  hemorrhages  as  beneficial, 
while  others  have  regarded  them  as  always  of  dangerous 
significance. 

My  own  experience  leads  me  to  the  belief  that  when  the 
hemorrhage  is  scanty  it  has  little  influence  on  the  final  re- 
sult. When  it  occurs  before  the  twelfth  day  of  the  fever, 
it  often  does  good  by  relieving  the  intestinal  congestion. 
But  when  profuse,  or  even  a  slight  hemorrhage  after  the 
twelfth  day,  is  an  unfavorable  symptom  and  renders  the 
prognosis  unfavorable.  The  occurrence  of  the  hemorrhage 
renders  it  probable  that^ulceration  has  extended  to  the  ves- 
sels beneath  the  transverse  muscular  fibres  of  the  intestine, 
and  such  ulceration  is  very  aj^t  to  go  on  to  perforation  and 
a  fatal  peritonitis.  So  that  although  the  patient  may  sur- 
vive the  hemorrhage,  there  is  great  danger  of  death  from 
peritonitis,  and  this  danger  must  always  enter  into  your 
prognosis,  whether  the  hemorrhage  is  slight  or  severe. 

The  influence  of  age  is  very  great  in  determining  the  prog- 
nosis in  any  case  of  tyj)hoid  fever. 

The  prognosis  is  much  better  in  children  than  in  adults. 
Occurring  in  persons  over  forty  years  of  age,  the  prognosis 
is  decided.ly  unfavorable,  even  though  the  symptoms  may 
not  indicate  a  severe  type  of  the  disease. 

In  the  case  of  those  individuals  who  habitually  use 
alcoholic  stimulants,  whose  power  of  resistance  to  high 
temperature  is  diminished,  the  rate  of  mortality  is  very 
great. 

The  puerperal  state  renders  your  prognosis  especially 
unfavorable.  The  danger  to  the  patient  is  equally  great, 
whether  the  fever  comes  on  prior  to  delivery  or  during 
puerperal  convalescence. 

In  this  fever  there  is  greater  danger  to  those  who  are  guf- 


nioc.NOSis.  63 

fi'iiiiu;  from  any  rorni  of  clironic  disease  tliaii  to  those  who 
aiv  ill  a  healthy  condition  at  tiie  tinie  of  tlie  attack. 

Wiihout  delaying  you  longer  with  those  conditions  in 
the  ordinary  course  of  the  disease  wliicli  intluence  its  prog- 
uo^^is — the  most  ini])ortant  of  wliich  have  been  referred  to 
under  the  head  of  synii^tonis— I  will  ]>ass  to  the  considera- 
tion of  the  coini)lications  which  inlluence  its  prognosis. 
Thev  are  more  numerous  than  those  in  any  other  disease. 

l\vill  hr.-r  l.iirlly  :illude  to  tliose  which  are  intimately 
connect(>d  with,  or  de])endent  upon,  the  morbid  changes 
ordinarily  incident  to  the  disease,  and  afterwards  speak  of 
those  which  may  be  designated  as  accidental  complications. 

The  parenchymatous  changes  which  take  place  in  the 
different  organs  oi"  the  body,  during  the  progress  of  this 
fever,  necessarily  intluence  prognosis.  For  instance,  the 
muscular  degenerations  of  the  cardiac  walls  and  the  conse- 
quent loss  of  heart-power,  which  favors  pulmonary  and 
other  hypostatic  congestions,  and  the  diiiiinished  quantity 
of  blood  sent  to  the  various  tissues  of  the  body,  interfere 
more  or  less  with  their  nutrition.  Necrotic  and  gangrenous 
processes,  sometimes  met  with  in  the  cellular  tissues  of  the 
surface  and  along  the  line  of  the  intestines,  also  the  venous 
thrombi  which  so  frequently  develop  in  a  protracted  case 
of  this  fever,  are,  to  a  certain  extent,  the  result  of  this  car- 
diac weakness.  It  is  apparent  that  the  dcn-elopment  of  ex- 
tensive cardiac  degenerations  must  render  the  prognosis 
unfavorable. 

Excessive  cardiac  weakness  favors  the  development  of 
blood-clots  in  the  heart-cavities ;  these  may  break  up  and 
cause  embolism  somewhere  in  the  course  of  the  general  cir- 
culation, and  thus  lead  to  changes  which  may  destroy  life. 
Again.  I nhsU nttJ  jyrrf orations,  one  of  the  results  of  the  in- 
testinal changes  incident  to  the  fever,  render  the  prognosis 
most  unfavorable.  The  same  is  true  of  co-plons  intestinal 
licinorrlKKjt'S  coming  on  after  the  third  week  of  the  fever, 
as  well  as  of  all  th<.)se  glandular  changes  which  are  a  part  of 
til.'  naluial  hi-lory  of  the  fever,  and  which  I  liavr  already 
described. 

Any  of  these  changes  may  h-ad  to  complications  which 


54  TYPHOID    FEVER. 

endanger  tlie  life  of  the  patient,  and  conseqnently,  when 
they  occur,  necessitate  a  guarded,  if  not  an  unfavorable 
prognosis. 

Some  of  the  prominent  accidental  complications  which 
may  occur  in  the  course  of  typhoid  fever,  but  which  do  not 
belopg  to  its  regular  history,  have  their  seat  in  the  respira- 
tory organs.  Slight  bronchial  catarrh  is  present  in  nearly 
every  case,  and  can  hardly  be  regarded  as  a  complication. 
It  is  so  much  a  part  of  the  clinical  history  of  the  disease, 
that  some  have  named  this  fever  hronclilal  iyplius.  Tliere 
is  another  much  more  serious  bronchial  complication, 
namely,  catarrh  of  the  smaller  bronchi,  or  capillary  bron- 
chitis. This  usually  comes  on  during  the  second  or  third 
week  of  the  disease,  and  if  extensive,  greatly  endangers  the 
life  of  the  patient.  If,  then,  during  this  period  of  the  fever, 
you  have  subcrepitant  rales  suddenly  developed  over  the 
whole  of  both  lungs,  accompanied  by  great  dyspnoea  and 
an  abundant  expectoration  of  stringy  mucus,  you  are  war- 
ranted in  giving  an  unfavorable  prognosis. 

Extensive  oedema  of  the  lungs  occurring  wdth,  or  inde- 
pendent of,  capillary  bronchitis  and  pulmonary  congestion, 
sometimes  comes  on  suddenly  during  the  third  week  of 
typhoid  fever,  and  indicates  great  failure  of  heart-jDower. 
The  slightest  indication  of  its  occurrence  should  alwa3^s  be 
regarded  with  suspicion.  It  is  not  unfrequently  accom- 
panied by  more  or  less  extensive  hemorrhagic  infarctions 
of  the  lungs  ;  these  depend  on  embolism  of  some  of  the 
branches  of  the  pulmonary  artery  due  to  fragments  of  clots 
which  have  formed  in  the  right  side  of  the  heart,  the  result 
of  the  cardiac  weakness  ;  these  often  lead  to  gangrene  of 
the  lung.  It  is  sometimes  impossible  to  diagnosticate  their 
existence  during  life. 

Pneumonia,  when  it  complicates  tyi:)hoid  fever,  is  gener- 
ally latent.  It  comes  on  very  insidiously,  and  unless  you 
are  on  the  watch  for  its  development,  and  make  frequent 
and  careful  physical  examination,  it  will  pass  unrecognized. 
It  is  more  frequently  developed  during  the  third  and  fourth 
wTek  of  the  fever,  and  usually  is  catarrhal  rather  than 
croupous  in  character.     At  first  only  single  lobules  are  in- 


rnooNosis.  55 

volvcd.  hilt  nfttT  a  flinc  an  oiitiiv  lob<»  becomes  consoli- 
dated. W'lii'ii  irregulai-  variations  in  teinjxTatuiv  occnr 
(hiiiiig  convalescence,  or  during  the  third  or  fourth  week  of 
the  fever,  there  is  reason  to  suspect  the  development  of 
pneumonia.  In  the  majority  of  cases  tlie  charaeteiistic 
pneumonic  cough  and  expectoration  are  absent.  W'litii- 
ever  an  extensive  pneumonia  conii)licates  typhoid  fever,  tlic 
prognosis  is  especially  unfavorable. 

Pleurisy  does  not  occur  so  frequently,  as  a  complication 
of  tyjdioid  fever,  as  does  pneumonia  or  bi-onchitis.  AVhen 
it  does  occur,  the  almost  invariabl<'  product  of  the  inliam- 
matory  process  is  pus.  Usually  it  comes  on  late  in  the  dis- 
ease, comes  on  insidiously,  and  is  quite  likel}'  to  ])ass  un- 
recognized unless  frequent  physical  examinations  of  the 
chest  are  ma(h^  In  many  instances  it  is  really  a  sequela  of 
the  fever,  not  develo})ing  until  three  or  four  weeks  after  the 
fever  has  run  its  course.  Its  occurri*nce  must  alwa3'S  be  re- 
garded as  unfavorable,  for  a  3'ear  or  even  longer  time  must 
elapse  before  recovery  can  take  place,  and  even  then  recov- 
ery is  doubtful. 

Occasionally  laryngitis  is  a  serious  complication  of  this 
fever.  It  generally  occurs  in  those  cases  where  the  fever 
lias  been  very  protracted,  and  there  is  great  prostration. 
Its  presence  is  marked  by  sudden  and  very  intense  intlam- 
mation  of  the  mucous  membrane  of  the  glottis,  which  is  lia- 
ble to  become  oedematous,  when  death  may  suddenly  occur. 
It  may  lead  to  ulceration  of  the  mucous  niembiane.  AVlnni- 
ever,  during  any  stage  of  a  typhoid  fever,  the  characteristic 
symptoms  of  laryngeal  obstruction  occur,  remember  the 
danger  of  oedema  glottidis  and  of  extensive  laryngeal  ul- 
ceration, and  promptly  resort  to  those  means  which  shall 
relieve  the  unpleasant  sym]»toms.  and  avert  the  danger 
which  threatens  your  })atlent. 

P3'aMiiia  maybe  met  wiili  as  a  complication  dui'ing  con- 
valescence from  ty})hoid  fevei-,  l)ut  it  is  not  of  as  frequent 
occurrenc(?  as  sei)ticnMiiia.  Wlu-never  we  have  septic  poi- 
soning developed,  with  extensive  sloughs  in  the  intestines, 
the  })rognosis  is  exceedingly  unfavoiabje. 

Acute  gastric  catarrh  is  another  complication  of  this  fever, 


56  TYPHOID    FEVER. 

the  possible  occurrence  of  which  must  enter  into  your  prog- 
nosis. A  patient  may  have  reached  his  fourth  week,  and 
be  rapidly  convalescing,  his  desire  for  food  returning  ;  you 
endeavor  to  hasten  his  recovery  by  increasing  the  quantity 
of  food  taken,  or  by  allowing  him  to  partake  freely  of  such 
articles  of  food  as  are  difficult  of  digestion.  The  result  of 
this  overcrowding,  or  of  imprudence  in  diet,  is  irritation 
and  inflammation  of  the  enfeebled  gastric  mucous  mem- 
brance.  Vomiting  of  a  stringy  mucus  occurs,  which  by  its 
prostrating  effects  endangers  or  destroys  the  life  of  your 
already  enfeebled  patient.  I  would  impress  you  with  the 
importance  of  exercising  the  greatest  care  in  regard  to  the 
diet  of  patients  convalescing  from  typhoid  fever.  They 
should  be  restricted  to  milk  and  nutritious  broths  in  mode- 
rate quantity  until  all  danger  from  this  complication  shall 
have  passed. 

Disturbances  of  nerve-function  have  been  considered  un- 
der the  head  of  symptoms,  but,  not  unfrequently,  certain 
brain  and  nerve  lesions  are  developed  which  cannot  be 
classed  under  that  head. 

Cerebral  oedema  may  complicate  a  typhoid  fever  during 
its  third  week,  and  give  rise  to  symptoms  of  a  grave  char- 
acter. A  decided  enfeebling  of  the  mental  powers  and  a 
tendency  to  stupor  announces  it  occurrence. 

Hemorrhagic  extravasations  on  the  surface  and  into  the 
substance  of  the  brain,  the  result  of  degeneration  of  the 
walls  of  the  cerebral  vessels,  occasionally  occurs  during  the 
height  of  the  fever.  If  the  effusion  is  moderate,  no  marked 
symptoms  are  developed  ;  but  if  a  considerable  extravasa- 
tion takes  place,  it  gives  rise  to  symj^toms  of  cerebral  com- 
pression. 

Meningeal  inflammation  is  a  rare  complication. 

The  occurrence  of  any  of  these  complications  in  any  case 
renders  the  prognosis  unfavorable. 

You  must  remember  tliat  during  the  second  or  third  week 
of  the  fever  certain  cerebral  disturbances  may  occur,  which 
seem  to  indicate  the  existence  of  some  one  of  these  compli- 
cations, when  really  no  cerebral  lesion  exists.  Usually, 
these  are  present  in  patients  who  have  had  a  continuously 


PKOGNOSIS.  57 

liigl]  teniperatare  ;  in  favorable  cases  they  disappear  after  a 
few  days.  These  liave  been  referred  to  under  the  head  of 
symptoms. 

You  will  encounter  various  other  disturbances  of  the 
nervous  system,  such  as  hemiplegia,  paraplegia,  etc.,  which 
may  simulate  those  due  to  lesions  of  nerve-centres,  or  local 
forms  of  pai-alysis  and  aufcsthesia,  which  seem  to  h>i  con- 
lined  to  individual  nerves  ;  but  as  these  functional  disturb- 
ances do  not  depend  upon  any  anatomical  changes,  the 
prognosis  in  such  cases  is  good. 

Those  changes  in  the  kidney  due  to  the  parenchymatous 
degeneration  which  usually  attends  this  fever,  have  been 
already  noticed  ;  but  occasionally  nephritis  is  developed  as 
a  sequela.  The  urine  becomes  scanty,  is  loaded  with  albu- 
men, and  contains  blood  and  casts  ;  the  face  and  extremities 
become  (Edematous,  and  death  may  occur  from  uraemia. 
The  occurrence  of  this  complication  necessarily  renders  the 
prognosis  bad. 

In  a  few  instances  under  my  observation,  severe  catarrh 
of  the  bladder  has  developed  during  convalescence,  greatly 
complicating  the  case  ;  in  one  instance  the  cystitis  was 
accompanied  by  pj^elitis. 

Snppurative  inflammation  of  the  cellular  tissue  of  the 
bod^-,  or  cellulitis,  (.^specially  of  the  surface,  often  compli- 
cates convalescence,  and  in  some  cases  causes  death.  It  is 
most  liable  to  develop  in  tliose  parts  which  havt'  been  sub- 
jected to  long-continued  pressure.  Occasionally  it  is  met 
with  in  the  pharynx  and  along  the  line  of  the  lymphatics 

Accompanving  these  cellular  inflammations,  or  occurring 
independently  of  them,  not  unfrequently  gangrenous  inflam- 
mations of  the  integument  occur,  giving  rise  to  what  has 
been  called  bed-sores.  These  gangrenous  processes  are  most 
frequently  developed  at  those  points  which  have  been  sub- 
jected to  the  greatest  pressure,  on  account  of  the  position 
of  the  ])atient  in  bed,  such  as  the  sacrum,  nates,  heels,  and 
shoulder-blades,  etc.  In  the  simplest  form  of  bed-sores 
there  is  only  a  superficial  loss  of  substance  ;  in  more  severe 
cases  the  subcutaneous  cellular  tissue  is  involved;  and  in 
the  worst  cases  the  muscles  and  fibrous  tissues.     I  have  met 


58  TYPHOID    FEVER. 

with  cases  where  the  slough  had  involved  the  connective 
tissue  and  muscles,  and  laid  bare  the  bony  tissue. 

A  considerable  number  of  typhoid  patients  who  have 
lived  through  the  fever,  die  either  from  the  exhausting 
effects  of  these  bed-sores,  or  from  the  septic  poisoning  re- 
sulting therefrom. 

The  possible  occurrence  of  these  complications  must  enter 
into  the  pi'ognosis  in  every  severe  case,  and  the  earlier  they 
make  their  appearance  the  greater  the  danger. 

We  have  now  completed  the  list  of  principal  complica- 
tions which  are  to  modify  your  prognosis  in  any  case  of 
typhoid  fever.  Before  leaving  the  subject,  I  will  say  a  word 
in  regard  to  the  duration  and  mode  of  termination  of  this 
fever. 

DuKATioisr. — Its  average  duration  is  from  three  to  four 
weeks ;  it  may  terminate  in  death  or  recovery  at  an  earlier 
date.  A  typical  case  extends  over  a  period  of  four  weeks. 
The  period  of  invasion  lasts  from  one  to  five  days.  The 
period  of  glandular  enlargement  continues  until  about  the 
fourteenth  day.  The  period  of  ulceration  extends  from  the 
twelfth  or  fourteenth  day  to  sometimes  between  the  twenty- 
first  and  twenty-eighth.  When  the  fever  is  protracted  be- 
yond the  middle  of  the  fourth  week,  in  most  instances  this 
is  due  to  some  complication,  or  to  an  extension  of  the  in- 
testinal ulceration.  The  period  of  greatest  danger  is  at  the 
close  of  the  third  week.  Death  rarely  occurs  before  the 
fourteenth  day.  The  prominent  direct  causes  of  death  are : 
First,  Toxcemia ;  Second,  Asthenia;  Third,  Suppression 
of  the  excretory  function  of  the  kidneys;  Fourth,  Hyper- 
cemia  and  oadenia  of  the  lungs ;  Fifth,  Intestinal  hemor- 
rhage ;  Sixth,  Exhaustive  diarrhoea ;  SeventJi,  Intestinal 
perforation ;  Eighth,  Peritonitis,  with  or  loithout  intesti- 
nal perforation.  In  nearly  all  cases  the  failure  of  heart- 
power  is  directly  or  indirectly  the  cause  of  death.  In  no 
case  can  convalescence  be  said  to  be  fairly  established  until 
the  temperature  remains  normal  for  two  successive  evenings. 
Its  termination,  like  its  commencement,  is  gradual,  and  it  is 
not  marked  by  any  critical  evacuation  or  day  of  crisis. 

Helapses. — After  typhoid  fever  has  run  its  course,  and 


RELAPSES.  50 

after  the  patient  is  entirely  fre»'  from  fever,  quite  frequiMitly 
we  have  a  new  (l»'vel()i)nit'nt  of  tlu'  fever  ;  these  iu*\v  dt'vrlop- 
nieiits  air  callt'd  relai)SfS.  Tlifir  eourse  corresi)oii(ls  with 
that  (>r  iIk'  primary  attack,  only  they  are  of  shortt-r  dura- 
tion. Tlie  tt'iupt-raturt'  rises  more  rapidly,  the  <'rui)tioii  \r- 
a})})eais,  the  s})lr('n  cnlariifs,  tiir  iiitrstinal  and  ahdominal 
symjitoiiis  rciiii  II.  and  all  the  I'loiiiiiK'nt  sym})toiiis  ol"  the 
primary  fever  arc  rajiidly  dcvclojii'd.  As  a  rule,  tin-  it'la))se 
is  mild.'r  than  llif  jirimary  attack.  If  it  tcnninates  fatally, 
the  })()st  luoittin  t'xaiiiiiiation  shows,  in  addition  to  the 
eicatrizin^H-  intestinal  ulcers  of  the  primary  attack,  the  re- 
cent intestinal  chani;-es  of  the  relapse.  The  lesions  of  the 
relapse,  although  of  the  same  character  as  those  of  the  pri- 
mary attack,  are  less  extensive. 

It  is  very  difficult  to  give  a  satisfactory  exi)lanation  of 
these  relapses.  Some  claim  that  they  are  the  result  of  cer- 
tain plans  of  treatment,  esi)ecially  the  cold-water  ])lan. 
This  assertion  lacks  proof.  Again,  others  hold  that  all  re- 
lapses depend  upon  a  new  infection.  Perhaps  this  is  pos- 
sible if  the  patient  remain  in  the  same  locality  and  has  the 
same  surroundings  as  when  he  had  the  primary  attack ;  but 
how  shall  we  explain  relapses  in  those  who  are  removed 
from  all  the  sources  of  the  primary  infection^  Another 
explanation  offered  is  that  a  part  of  the  typhoid  poison  has 
remained  in  the  system,  undeveloped  during  the  ])rimary 
attack,  and  that  some  time  after  this  has  passed  the  poison 
reproduces  itself  and  sets  up  a  second  fever. 

A  more  recent  theory  is,  that  the  typhoid  poison  thrown 
off  in  the  faeces  of  the  patient  is  reabsorbed  and  causes  the 
rela])se.  Unquestionably,  it  is  possible  for  ht^althy  glands 
to  l)ecome  inoculated  by  sloughs  thrown  off  from  those  lirst 
affected. 

In  many  cases  it  is  impossible  to  account  for  the  occur- 
rence of  the  relapse,  and  all  of  these  explanations  as  to  the 
cause  in  any  case  are  more  or  less  unsatisfactory. 

In  those  cases  which  have  come  under  my  own  observa- 
tion, I  liave  noticed  that  the  s])lenic  eidargeUK-nt  which  has 
existed  during  the  course  of  the  fever  does  not  subside  with 
its  decline;  ami   that  the  tenderness  along  the  line  of  the 


60  TYPHOID    FEVER. 

intestines,  especially  in  the  right  iliac  region,  continues 
during  the  j)fii'iod  between  the  original  attack  and  the  re- 
lapse. In  some  instances,  apparently,  the  relapse  has  been 
brought  on  by  indiscretion  in  diet,  or  by  injudicious  exer- 
cise on  the  part  of  the  convalescent  patient.  Occasionally 
relapses  have  occurred  when  great  care  had  been  taken 
against  any  indiscretion  or  over-exertion. 

There  is  little  doubt  but  that  relapses  are  of  much  more 
frequent  occurrence  in  those  cases  that  are  treated  with 
cathartics  during  the  first  week  of  the  fever,  than  in  those 
where  cathartics  are  not  emplo^^ed. 


LECTURE    VI. 


TYPHOID   FEVER. 
Treatment. 

Before  speaking  in  detail  of  the  treatment  of  typhoid 
fever,  I  will  say  a  few  words  concerning  its  prevention. 

If  the  modern  theory  (which  I  have  already  givon  yon) 
of  its  etiology  be  accepted,  the  qnestion  naturally  arises, 
cannot  the  typhoid  poison  be  prevented  from  entering  our 
dwellings,  or  polluting  our  driidving- water  ? 

Facts  prove  almost  conclusively  that  ty]ihoid  fever  is 
never  of  spontaneous  origin.  Should  it  occur  in  tlu'  locality 
where  you  may  reside,  if  possible  find  out  its  origin.  If  no 
case  has  ever  before  occurred  in  the  locality,  endeavor  to 
ascertain  the  manner  in  which  the  t3qihoid  poison  has  been 
introduced.  If  it  is  already  endemic,  limit  the  disease  to 
the  iirst  few  cases  by  a  most  thorough  disinfection,  and 
remove  all  those  surroundings  which  favor  the  reproduction 
of  the  typhoid  poison. 

If  the  theory  is  correct,  that  typhoid  fever  is  depcnih-nt 
upon  a  poison  contained  in  the  excrements  of  a  typhoid 
patient,  then  the  poison  should  be  destroyed  as  soon  as  it 
is  discharged  from  the  body.  For  tliis  purpose,  the  intes- 
tinal discharges  should  be  received  into  a  porcelain  bpd-])an, 
the  bottom  of  whicli  should  be  covered  with  a  thin  layer  of 
powdered  sulphate  of  iron  ;  immediately  after  the  discliarge, 
crude  muriatic  acid,  equal  in  quantity  to  one-third  of  the 
f{ccal  mass,  should  be  poured  over  it.  Never  emi)ty  the 
discharges  of  a  tyi)hoid  patient  (no  matter  how  tlioroughly 


62  TYPHOID    FEVER. 

they  may  have  been  disinfected)  into  the  privy  or  water- 
closet  used  by  the  family.  Trenches  should  be  dug  for 
their  reception,  and  new  trenches  should  be  opened  every 
few  days  ;  the  greatest  care  should  be  taken  that  these 
trenches  are  not  so  situated  that  drainage  from  them  can 
contaminate  wells  or  springs  which  furnish  drinking-water. 
All  under-clothing  or  bed-clothing  that  may  have  become 
soiled  by  the  discharges  from  the  bowels,  should  be  imme- 
diately immersed  in  chlorine  water,  and  thoroughly  boiled 
within  twenty-four  hours.  This  procedure  will  certainly 
destroy  the  infective  i^ower  of  the  typhoid  poison  contained 
in  the  intestinal  discharges,  and  in  the  majority  of  instances 
you  will  prevent  the  spread  of  the  fever. 

Repeated  observation  shows  that  when  one  member  of  a 
family  has  typhoid  fever,  not  unfrequently  it  is  developed 
in  every  other  member.  This  spread  of  the  disease  can  be 
prevented,  unless  there  is  some  local  cause  for  its  develojD- 
ment  which  cannot  be  reached. 

When  its  origin  is  not  apparent,  the  wells,  springs,  and 
all  the  sources  from  whence  water  is  derived  for  drinking 
and  cooking  purposes  should  be  carefully  and  thoroughly 
inspected.  Care  must  be  taken  that  the  waste-pipes  from 
wells  and  springs  do  not  pass  directly  into  cesspools  or 
sewers,  and  thus  become  a  means  for  the  conveyance  of 
impure  gases  into  the  springs  and  wells. 

The  greatest  care  must  also  be  exercised  in  regard  to  home 
drains  and  sewer-pipes,  that  they  shall  be  free  from  leakage 
and  obstruction,  and  that  all  water-closets,  sinks,  and 
other  openings  into  them  be  provided  with  suitable  traps. 

When  unpleasant  odors  are  constantly  present  in  dwell- 
ings, especially  in  sleeping  apartments,  disinfectants  should 
be  employed,  and  the  house  be  thoroughly  ventilated. 

When  it  may  be  necessaiy  to  open  drains  and  cesspools 
in  a  dwelling  for  purposes  of  repair  or  cleansing,  the  same 
precautions  should  be  exercised;  these  are  especially  of 
importance  during  the  summer  and  autumn. 

In  conclusion,  let  me  impress  upon  you  this  fact,  that 
when  typhoid  fever  is  carried  from  the  sick  to  the  healthy, 
the  evacuations  are  the  chief,  if  not  the  only  means  of  con- 


TKKATM?:\T.  03 

tamination  ;  consequontly,  tlio  iinporfanro  of  thnronuMily 
disinftH-tiiiu;  tlic  cxcnMin'iits  of  tyitlioid  patients  sliould 
always  bo  home  in  mind. 

In  tliis  coniiiMrion  the  question  naturally  arises,  can  we 
not  counteract  or  neutralize  the  effects  of  tlie  fevei-  ])()ison 
after  it  has  <;ain''(l  admission  into  the  system,  ami  thus 
prevent  the  develo]unent  of  typhoid  fever?  To  acc()m])lisli 
this,  at  one  time  blood  letting  was  resorted  to  ;  but  at  the 
presi'Ut  day  few  i)ractitioners  would  venture  to  suggest 
such  a  plan  of  treatment,  and  few  patients  could  be  found 
willing  to  submit  to  it.  Plmetics  were  given  on  th««  sup- 
])osition  that  the  fever-poison  acted  primarily  u])on  the 
mucous  membrane  of  the  stomach,  and  that  the  offending 
af'-ent  nii<'-ht  be  removed  by  their  early  administration,  and 
thus  its  absori)tion  into  the  system  prevent<'d.  As  it  has 
been  proved  that  the  typhoid  poison  can  be  introduced  into 
the  system  thnnigh  other  channcds  than  the  stomach,  and 
as  experience  has  shown  that  emetics  have  not  the  power  to 
prevent  the  development  of  ty])lioid  fever,  their  use  has 
been  abandoned.  Diaphoretics  have  also  been  eruployed  ; 
but  there  is  not  the  slightest  proof  that  typhoid  or  any 
fever-poison  was  ever  removed  from  the  system  by  sweating. 
A  patient  with  some  of  the  premonitory  symptoms  of  fever 
may  sweat,  be  relieved,  and  at  once  r<'cover,  but  such  a 
patient  has  not  received  the  typhoid  poison  into  his  system, 
and  was  not,  as  is  sometimes  said,  "  threateued  with 
typhoid  fever.'' 

Notwithstanding  the  bold  afRrmation  of  the  author  of  the 
cold  affusion  ])lan  of  treatment,  that  if  it  were  resorted  to 
before  the  third  day  of  the  disease,  it  would  invariably 
arrest  its  development,  it  has  failed  to  stand  the  test  of 
practical  experience. 

More  recently,  sulphate  of  ([uinine,  administered  in  large 
doses,  has  been  thought  to  have  the  power  of  arresting  the 
development  of  ty]ihoid  fever  in  the  same  way  that  it 
arrests  malarial  fever,  l)y  its  anti-periodic  power:  but  there 
is  no  evidence  that  it  has  any  such  power,  and  as  a  prophy- 
lactic remed}'  it  has  been  aband(uied. 

I  might  goon  almost  in'l"finit.*ly  "iiiim''rating  measures 


64  TYPHOID    FEVEK. 

wMcli  have  been  resorted  to  for  preventing  the  develop- 
ment of  this  fever ;  but  after  the  poison  has  once  gained 
entrance  into  the  system,  no  means  have  as  yet  been  dis- 
covered by  which  it  can  be  counteracted  or  neutralized  so 
as  to  prevent  the  development  of  the  disease.  The  duty  of 
the  physician  is  to  guide  the  disease,  so  far  as  he  may 
be  able,  to  a  favorable  issue,  and  prevent  injury  to  organs 
essential  to  life,  keeping  in  mind  that  a  certain  definite 
period  must  elapse  before  this  result  can  be  accomplished. 

Before  entering  into  a  detailed  account  of  the  treatment 
to  be  pursued  in  the  management  of  a  case  of  typhoid 
fever,  I  will  say  a  few  words  in  reference  to  the  arrange- 
ment of  the  sick-room  of  fever  patients.  Though  often 
overlooked,  this  is  a  matter  of  no  inconsiderable  impor- 
tance, not  only  as  regards  the  comfort  of  the  patient,  but  it 
has  much  to  do  with  the  successful  issue  of  the  case. 

It  is  of  the  greatest  importance  that  a  properly  qualified 
nurse  be  selected  ;  one  who  has  had  experience  in  the  care 
of  fever  patients  is  to  be  preferred.  In  the  next  place,  the 
patient  should  be  placed  in  a  large  and  well-ventilated 
apartment.  All  furniture  should  be  removed  from  the  sick- 
room, except  those  articles  which  are  necessary  for  the  com- 
fort of  the  patient  and  the  convenience  of  the  attendants. 
Remove  the  carpets  from  the  floor,  place  your  patient  in  a 
bed  of  moderate  size  in  the  centre  of  the  room,  and  let  there 
be  free  ventilation  during  both  day  and  night. 

The  temperature  of  the  apartment  (if  possible)  should  be 
kept  below  60°  F. 

The  bed  and  body  linen  of  the  patient  should  be  changed 
daily,  and  at  once  be  removed  from  the  sick-room  and  placed 
in  a  weak  solution  of  chloride  of  sodium  ;  especially  is  this 
important  if  the  patient  is  having  frequent  discharges  from 
the  bowels.  The  apartment  should  be  kept  perfectly  quiet, 
the  light  subdued,  and  only  the  attendants  should  be  al- 
lowed in  the  room. 

These  preliminary  arrangements  having  been  made,  we 
will  suppose  we  have  in  charge  a  patient  with  a  mild  type 
of  typhoid  fever.  All  medicinal  interference  in  such  a 
case  is  unnecessary.     The  treatment  resolves  itself  into  the 


TlIKATMKNr.  0;") 

arrangement  of  the  sick-room  and  ])roper  diet  ;  milk  is  i»ie- 
fe ruble, //7///.S'  are  not  to  he  allowed  hi  ((n if  case.  In  the 
miklest  case  this  care  in  diet  is  important,  and  the  patient 
shonkl  be  kept  in  bed  nntil  convahiscence  is  fnlly  estab- 
lislied.  This  should  be  insisted  H])on  in  the  mild  as  well 
as  the  severe  cases. 

As  I  liave  already  stated,  the  temptMature  in  a  mild  type 
of  this  fever  rarely  rises  above  lo:f  F.  ;  therefore  there  is 
no  necessity  for  resorting  to  antipyretic  measures  ;  frequent 
sponging  of  the  surface  with  cold  or  tepid  water,  as  is  most 
agreeable  to  the  patient,  will  be  found  of  service. 

By  far  the  larger  number  of  cases  of  this  fever  are  of  a 
more  severe  type,  and  though  in  your  treatment  you  must 
be  guided  by  the  circumstances  which  attend  each  indi- 
vidual case,  usually  you  will  be  obliged  to  resort  to  more 
decided  measures. 

Remember  that  there  are  no  specifics  for  this  disease  ;  all 
of  those  which  have  been  proposed  and  employed  have 
either  fallen  into  disuse,  or  are  resorted  to  only  as  aids  in 
general  treatment. 

Typhoid  fever  is  a  disease  that  has  certain  stages  to  pass 
through,  limited  only  by  days  and  weeks.  There  is  great 
doubt  whether  the  physician  can  shorten  its  duration  by  a 
single  day,  but  experience  warrants  the  belief  that  many 
lives  may  be  saved  by  remedial  measures  used  at  the  proper 
time,  and  combint'd  with  Judicious  hygienic  management. 

There  are  critical  periods  in  this  disease  ;  bf  ])r<'])art'd  bv 
knowledge  and  judgment  to  carry  your  ])atient  (if  possible) 
safely  through  them.  Umpit'stionably  one  of  the  most 
important  things  to  be  accomplishfd  is  the  reduction  of 
temperature,  or  rather  the  keeping  of  the  temperature  below 
a  certain  standard.  P.lood-h'tting.  em»4ics,  dia]>hon'tics. 
cathartics,  chlorine  water,  and  mineral  a<'ids  hav.-  all  b.'.>n 
resorted  to  in  order  to  reduce  temperature.  The  last  two 
agents  were  supposed  to  reduce  temperature  by  neutrali/ing 
the  typhoid  poison.  At  the  ])resent  day  1  think  there  is  no 
intelligent  physician  who  imagines  he  can  neutralize  the 
typhoid  poison,  and  thus  reduce  temperature,  while  only  a 
few  years  ago  these  ag'-iiN  were  supposed  to  ]»oss.'ss  such 


66  TYPHOID    FEVER. 

power,  and  were  very  extensively  employed  for  such  a 
purpose  by  some  intelligent  physicians. 

The  agents  which  more  recently  have  been  employed  for 
this  purpose,  namely,  sulphate  of  quinine  and  cold  applica- 
tions to  the  surface,  are  powerful  agents  in  reducing  the  tem- 
perature and  lessening  the  severity  of  the  disease  ;  but  they 
can  never  shorten  its  duration,  and  if  you  employ  them,  ex- 
pecting this  result,  you  will  be  greatly  disappointed.  It  is 
claimed  by  many  very  distinguished  observers  of  the  jjres- 
ent  day  that  the  parenchymatous  degenerations  of  the  dif- 
ferent organs  and  tissues  of  the  body,  which  are  found  in 
those  who  die  of  typhoid  fever,  are  due  to  the  prolonged 
high  temperature  which  is  present  during  the  course  of  this 
disease ;  but  as  yet  there  are  no  facts  to  prove  this  asser- 
tion, for  the  same  parenchymatous  changes  are  found  in  the 
bodies  of  those  who  have  died  of  diseases,  the  course  of 
which  was  not  marked  by  high  temperature,  and  did  not 
extend  over  a  period  of  more  than  forty-eight  hours.  So 
far  as  we  are  able,  to  determine  by  analogy  upon  what  these 
parenchymatous  changes  depend,  we  are  led  to  believe  that 
the  s]3ecific  poison  of  the  disease  has  more  to  do  with  their 
development  than  the  high  rate  of  temperature.  One  thing 
must  be  apparent  to  every  clinical  observer :  that  the 
injurious  effects  of  a  prolonged  high  temperature  are  early 
and  most  markedly  shown  by  disturbances  of  the  cerebro- 
spinal system.  It  is  still  an  unsettled  question  whether 
these  disturbances  are  due  to  the  primary  changes  in  the 
constituents  of  the  blood,  which  always  accompany  a  high 
range  of  temperature,  or  to  the  direct  effects  of  the  high 
temperature  on  the  nerve  centres. 

Whichever  view  we  accept  or  adopt,  the  employment  of 
those  means  which  have  the  power  of  safely  reducing  tem- 
perature is  indicated,  and  when  judiciously  used  they  have 
much  to  do  with  the  safety  of  the  patient. 

All  those  means  which  have  been  employed  for  the 
reduction  of  temperature  are  included  under  the  general 
term  of  antipyretics,  and  the  treatment  of  disease  by  the 
use  of  these  agents  has  received  the  name  of  antipyretic 
treatment. 


TUKA'I'MKXT.  (57 

I'liqiiostioiKihly  tlir  iiiosl  cflicieiit  and  rdiaMr  i>\'  I  lie 
aiiti])vi-i'lic  an'cnts  ai-i"  I  he  cxlci-iial  apjilicatioii  of  cold  liy 
incaiis  of  hallis.  ))a('ks,  and  cll'ii^ioiis,  and  tin-  iiihTnal 
atlininistrafioii  of  llic  snlplialc  of  (|uiiiiii('.  TIh'  (luiiiiiir  is 
not  adniinisd'ivd  lo  ])i(i(luct'  an^'  sjx'cilic  acLion  njion  llu; 
ty))li(>id  fever  jxiison,  hnl  is  employed  for  its  ant ipy relic 
[)()\ver.  Tliciv  are  other  anti])yi'etic  afz;ents  besides  these 
two,  but  tln\v  are  of  so  little  importance  that  it  is  necessary 
to  give  (hell)  (.nly  a  ])assing  notice  after  we  shall  have  con- 
sidered these  two  imjiortant  ones. 

At  the  ]iresent  time  the  opinion  prevails,  to  a  great  ex- 
tent, that  the  ap])lication  of  cold  to  the  surface  is  the  gn^at 
antij^yretic  in  the  treatment  of  fever.  This  is  no  new 
teacliing.  Long  ago  Dr.  Currie  recommended  the  applica- 
tion of  cold  to  the  surface  of  the  body  for  the  purpose  of 
i-apidly  i-educing  temperature,  and  proved  that  it  had  such 
an  effect ;  j^et  it  was  never  very  geneially  practised,  and 
soon  fell  into  disuse,  as  there  was  nothing  reliable  to  guide 
one  in  its  application.  As  we  now  have  the  thermometer 
to  guide  us  in  its  application,  more  recently  it  has  been 
resorted  to  with  considerable  success. 

I  will  give  you  some  general  rules,  which  may  be  of  ser- 
vice to  you  in  the  use  of  this  antipyretic  in  the  treatment 
of  ty]ihoid  fever. 

As  soon  as  the  axillary  temperature  in  the  evening  rises 
above  103°  F.,  place  the  patient  in  a  water-bath  having  a 
temperature  of  70°  F.  or  80°  F.,  and  gradually  lower  that 
temperature  by  the  addition  of  cold  watei- or  ice,  until  the 
temperature  of  the  i)alienl  begins  to  fall.  Vmu  may  lie 
compelled  to  lower  the  tempei-atuie  of  the  l>ath  to  do  F. 
before  the  temperature  of  the  ]iatient  is  alTected  ;  but  the 
lowering  of  the  bod}^  temperature  must  be  acconi]ilislied  i)y 
the  lowering  of  the  tem])eiature  of  the  bath,  taking  can^ 
that  the  latter  does  not  fall  below  60°  F.  When  the  tem- 
perature begins  to  fall,  renew  your  thermonietrical  observa- 
tions every  two  or  thr<*e  minutes.  While  the  baths  are 
being  used,  the  ti'm])ei;itiiie  must  betaken  ])y  ]»lacing  the 
thermometer  in  the  rectum.  If  it  falls  ra])idly — that  is, 
two  or  three  degrees  in  live  or  six  minutes — as  soon  as  the 


68  TYPHOID    FEVEK, 

fall  has  reached  103°  F.  remove  your  patient  from  the  bath  ; 
if  it  falls  slowly,  as  soon  as  it  reaches  101°  F.  he  should  be 
removed  and  imnn^diately  placed  in  bed.  Never  keep  the 
patient  in  the  bath  until  the  temperature  shall  have  reached 
the  normal  standard  ;  should  you  do  so,  he  may  pass  from 
a  condition  of  fever  into  a  state  of  collapse,  as  the  tempera- 
ture continues  to  fall  for  some  time  after  his  removal  from 
the  bath.  While  in  the  bath,  cold  should  be  applied  to  the 
head  by  means  of  a  sponge  wet  in  cold  water  or  by  an  ice-bag. 

The  cold  pack  is  much  less  effective  than  the  bath  ;  but 
if  the  patient  is  too  feeble  to  be  moved,  it  may  be  employed 
with  benelit.  You  should  wrap  the  patient  in  a  sheet  wrung 
out  of  tepid  water,  and  over  this  sheet  apply  one  wrung  out 
of  cold  water.  The  latter  may  be  removed  as  often  as  it 
becomes  warmed  ;  its  application  and  removal  may  be  con- 
tinued until  the  desired  fall  in  temperature  shall  be  obtained. 

In  severe  cases,  during  the  first  and  second  weeks,  you 
Avill  lind  that  after  the  temperature  has  been  reduced  by 
the  application  of  cold  to  the  surface,  it  will  begin  slowly 
to  rise  until  it  reaches  its  former  height.  Usually  one  to 
three  hours  will  elapse  before  it  begins  to  rise,  and  from 
two  to  six  before  it  reaches  its  former  height.  You  will 
then  be  obliged  to  repeat  the  baths  or  packs,  and  to  con- 
tinue their  use,  both  day  and  night,  from  three  to  six  times 
during  the  twenty-four  hours,  if  you  expect  to  keep  the 
temperature  below  103°  F.,  and  accomplish  anything  by 
this  plan  of  treatment.  My  experience  in  the  use  of  cold 
applications  leads  me  to  believe  that  unless  you  are  able  to 
maintain  a  low  range  of  temperature  after  four  or  five 
baths,  you  gain  very  little  by  their  continuance.  In  other 
words,  if,  after  using  the  baths  for  twenty-four  hours,  the 
temperature  of  your  patient  rapidly  rises  to  the  same  or  a 
higher  degree  than  it  was  before  their  use  was  commenced, 
you  will  obtain  little  or  no  benefit  from  their  continuance 
unless  you  can  introduce  some  other  agent  which  shall 
maintain  the  low  temperature  reached  by  the  bath.  I  am 
also  convinced  that,  after  the  second  week  of  typhoid  fever, 
cold  baths  should  not  be  employed  to  reduce  temperature, 
for  by  their  continuous  use  after  that  period  they  may  do 


THE  ATM  K  NT.  GO 

great  liann.  Tlu^  condition  of  a  lyplioid  ])ati(>nt  diiriiif^  tiie 
first  and  second  week  of  I  lie  frvcr  is  veiy  d  lift 'rent  from 
tiiat  during  tlie  thinl  and  fourth  weelv.  Durini:;  this  latter 
])eri()d  tliere  is  great  danger  of  colhi]t>r  afirr  a  cold  batli, 
and  in  several  instances  I  am  confident  that  }>ulmonary 
coni}>lications  have  l)een  the  result.  In  a  few  instaiiirs  the 
teniix'ial  uie  can  In-  very  rapidly  jdwcrcd  1)\-  ilif  a|t]iliralion 
of  ice-hags  to  the  abdomen.  The  rajtidity  with  which  the 
tem])erature  can  be  reduced  iisuallj'  (h'j)ends  ujion  the 
severity  of  the  i'l'vci-.  In  some  cases,  whrn  the  patient  is; 
placed  in  the  cold  bath,  the  temjx'rature  will  immt'diatdy 
begin  to  fall  ;  in  other  cases  there  will  be  a  gradual  reduc- 
tion of  temperature  as  the  water  is  made  cooler.  In  ceiiain 
severe  cases,  you  may  keep  a  patient  in  a  bath  of  the  teuj- 
perature  of  C()°  F.  for  the  space  of  half  an  liour  without 
the  temperature  falling  a  degree.  These  cases  are  exceed- 
ingly grave  in  character,  and  you  sliould  use  the  bath  with 
great  care. 

Finally,  let  me  impress  upion  3'ou  tliat  in  t3'phoid  fever, 
in  order  to  reduce  the  tem])erature,  3'oii  must  not  indiscrim- 
inately apply  cold  to  the  surface  of  the  body.  Perhaps  there 
is  no  remedial  agent  wliicJt  requires  greater  care  and  judg- 
ment in  its  use  ;  yet  doubtless,  when  judiciously  employed, 
the  lives  of  many  typhoid  patients  may  be  saved,  and  it  is 
equally  certain  that  when  injudiciously  employed,  many 
lives  may  be  destroyed.  If  you  use  the  cold  baths  in  con- 
junction witli  other  means  for  reducing  temperature  (con- 
cerning which  I  will  s])eak  at  my  next  lecture),  I  am  con- 
fident you  will  accomplish  much  ;  but  if  you  rely  oidy  \\\)0\\ 
the  baths,  in  the  majority  of  instances  you  will  be  disap- 
pointed in  the  result.  At  the  present  time  it  seems  to  me, 
that  by  some  the  benefit  and  ])Ower  of  cold  baths  in  the 
treatment  of  ty})hoid  fever  have  been  overrated. 

The  general  condition  of  your  patient  and  the  stage  of  the 
fever  must  be  considered  ;  also  the  effects  of  the  tiist  few 
baths  must  be  car<»fully  noted. 

Should  a  paticMit's  temperature  range  at  1(>4'  F.  or  l(>o° 
F.,  there  is  no  positive  evidence  that  you  must  resort  to  a 
cold  bath,  or  that  a  c(»ld  bath  is  the  best  agent  to  be  em- 


70  TYPHOID    FEVER. 

ployed  for  its  reduction.  Again,  if  the  patient  after  the 
second  or  third  bath  is  more  quiet,  has  less  delirium  (if 
delirium  previously  existed),  if  his  breathing  becomes  easy 
and  natural,  if  the  heart' s  action  is  more  regular  and  for- 
cible, and  he  falls  asleep  and  perspires,  there  can  be  no  ques- 
tion in  regard  to  the  beneficial  effects  of  the  bath.  If,  on 
the  other  hand,  the  bath  is  followed  by  feebler  heart's  ac- 
tion, by  dusky  cheeks,  by  rapid  respiration,  and  by  cold- 
ness of  the  extremities,  from  which  condition  the  patient 
rallies  slowly  and  imperfectly,  you  may  be  certain  that, 
however  high  the  temperature  may  range,  you  will  do  harm 
by  continuing  the  baths.  When  the  extremities  are  cold, 
or  there  is  profuse  hemorrhage  from  the  bowels,  or  Avhen, 
from  any  cause,  there  is  great  feebleness  of  the  heart's  ac- 
tion, and  especially  in  the  case  of  aged  persons,  cold  baths 
are  contraindicated. 

Cold  compresses  or  ice-bags  applied  to  the  abdomen,  in 
addition  to  their  beneficial  effect  on  the  intestinal  changes 
which  constitute  such  an  important  element  in  the  history 
of  tills  fever,  often  have  great  power  in  reducing  the  gen- 
eral heat  of  the  body,  I  have  also  in  some  instances  found 
the  body  temperature  rapidly  lowered  by  injections  of  ice- 
water  into  the  rectum.  Care  must  be  exercised  that  the 
cold  injections  are  not  administered  too  rapidly  or  in  too 
large  quantities. 

Although  this  mode  of  abstracting  heat  and  the  lowering 
of  the  body  temperature  is  never  so  effective  as  by  baths 
and  packs,  still  it  has  this  advantage,  that  no  such  compen- 
sating increase  in  the  production  of  heat  follows  the  use  of 
the  cold  injections  as  follows  the  cooling  of  the  external 
surface  by  the  baths. 

In  many  cases  the  extreme  obstinacy  of  the  fever,  which 
resists  the  most  systematic  use  of  cold,  as  well  as  the  fact 
that  some  patients  cannot  bear  a  sufficiently  frequent  repe- 
tition of  them  to  effect  the  desired  result,  or  that  there  may 
be  contra-indications  to  their  use,  necessitates  the  employ- 
ment of  other  means  for  the  reduction  of  the  body  temper- 
ature. To  these  I  shall  invite  your  attention  at  my  next 
lecture. 


LECTURE  VII. 


TYPHOID   FEVEll. 
Treatment  {continued). 

We  liave  already  considered  the  antipyretic  power  of 
cold  api)lications  in  the  treatment  of  typhoid  fever,  and  I 
will  now  oall  your  attention  to  the  antipyretic  power  of  the 
i>uli)liate  of  quinine. 

When  quinine  is  employed  as  an  antipj^retic,  it  must  be 
given  in  large  doses  ;  the  administration  of  two  grains  every 
two  hours,  or  a  larger  quantity  administered  in  divided 
doses  within  a  period  of  twenty-four  hours,  will  not  act  as 
an  antipyretic  ;  but  thirty  or  forty  grains  must  be  adminis- 
tered within  a  ])eriod  of  two  hours. 

If  the  stomaeli  is  irritable,  and  you  fear  that  a  large  dose 
will  produee  vomiting,  teu  grains  may  be  given  every  half 
hour  until  the  desired  quantity  has  V)ee'n  administered. 

Usually  from  four  to  six  hours  after  the  antipyretic  dose 
has  been  taken,  the  fall  in  temi)erature  will  l)egin,  and  in 
about  twelve  hours  it  will  reach  its  minimum  height  ;  then 
it  will  remain  stationary  from  twelve  to  twenty-four  hours. 
After  the  tem])erature  has  once  been  reduced  by  the  (piinine, 
its  administration  may  be  discontinued  until  the  tempera- 
ture shall  again  rise  to  105°  F.  As  a  rule,  the  tem})erature 
rarely  ranges  as  high  as  ])eroi-e  the  (piinine  was  administered. 

This  mode  of  administering  quinine  in  antij)yretic  doses 
to  fever  patients  rarely  jiroduces  any  s^^mptoni  of  cincho- 
nism,  other  than  a  tr.insient  deafness  after  the  first  dose. 
In  a  large  numb.-r  of  eases  the  temjierature  can  be  kept 


72  TYPHOID    FEVEK. 

below  103°  F.  by  tlie  sulphate  of  quinine  ;  but  in  very 
severe  cases  it  will  be  advisable,  and  sometimes  it  will  be 
absolutely  necessary,  to  employ  not  only  the  quinine,  but 
at  the  same  time  the  cold  baths.  My  rule  is,  after  I  have 
reduced  the  temperature  to  101°  F.,  or  102°  F.,  by  a  cold 
bath,  to  administer  an  antipyretic  dose  of  quinine,  and  thus 
delay  the  recurring  rise  of  temperature.  While  the  cold 
bath  more  rapidly  reduces  temperature,  the  effect  of  the 
quinine  is  more  lasting ;  consequently,  by  making  use  of 
both  of  these  reliable  antipyretics  during  the  first  two 
Aveeks,  you  will  be  able  to  control  the  temperature  during 
that  time.  After  this  period  it  is  not  safe  to  resort  to  cold 
baths  ;  but  when  the  temperature  rises  above  103°  F.,  oc- 
casionally you  may  use  the  cold  pack  in  connection  with 
antipyretic  doses  of  quinine.  If,  during  the  third  and 
fourth  weeks,  you  fail  to  reduce  the  temperature  by  these 
means,  administer  during  the  twenty-four  hours  from  ten 
to  twenty  grains  of  powdered  digitalis— unless  the  pulse  is 
very  frequent  and  irregular— when  its  use  is  contra-in- 
dicated. As  an  antipyretic,  digitalis  should  be  adminis- 
tered only  when  quinine  is  given.  It  seems  to  increase  the 
antipyretic  power  of  the  quinine,  but  has  little  or  no  power 
when  administered  alone. 

The  use  of  all  these  antipyretic  remedies  must  be  per 
sisted  in  until  the  desired  end— the  reduction  of  tempera- 
ture—is accomplished  ;  but  the  peculiarities  of  each  patient 
must  be  studied,  and  these  agents  must  be  so  administered 
as  to  suit  each  individual  case. 

You  cannot  trust  to  the  judgment  of  nurses  and  attend- 
ants, but  you  must  determine  for  yourself  what  are  the 
requirements  in  each  case. 

The  satisfactory  results  obtained  by  the  systematic  use 
of  these  remedies  Justifies  their  employment  ;  but  the  exact 
rules  which  are  to  govern  one  in  their  use,  as  to  manner 
and  time,  can  only  be  determined  by  experience. 

All  careful  observers  are  aware  that  great  danger  attends 
prolonged  high  temperature  ;  but  it  is  still  an  unsettled 
question  whether  this  danger  is  due  to  parenchymatous 
changes  in  the  different  organs,  which  some  claim  are  the 


TUKATMKXT.  t.i 

result  of  tho  liigli  tcinix'nitiiri',  <>i'  to  (listuibnnc(>  of  tlu* 
nerve  centres  from  the  isiinu'  caiLsc  Wlialcver  may  Ix'  tlie 
final  settlement  of  the  qiu'stion,  the  bendieial  results  which 
follow  the  antii)yreti(^  treatment  of  frvcrs  are  gcnnally 
admitted  ;  and  my  advice  to  each  oin'  of  you  is,  at  the 
outset  of  your  ])r<)fessi()nal  career  to  Miakr  yourself  perfectly 
familiar  with  the  use  of  these  most  imiioitant  and  reliable 
antipyretics. 

If  you  can  kee])  tli<'  tem]>eiat  me  of  your  jKiticnt  at  about 
103°  F.  during  the  tirst  two  weeks  of  the  fever,  you  have 
accomplished  the  Jlrst  and  ])erliaps  the  most  im})ortant 
thing  in  the  treatment  of  this  disease. 

To^iiixls  the  end  of  the  second,  or  during  the  third  week, 
sometinu'S  etii'lier,  sometimes  later,  signs  of  failure  of  heart, 
power  begin  to  manifest  themselves;  the  pulse  becomes 
feeble  and  irregular  ;  at  times  the  surface  is  cool  and  moist ; 
the  patient  complains  of  a  sense  of  exhaustion,  perhaps  is 
unable  to  turn  in  bed  ;  the  tongue  assumes  a  dry,  brown 
appearance,  and  the  necessity  of  supporting  the  patient 
becomes  apparent.  This  will  bring  you  to  the  second  im- 
portant question  in  the  treatment  of  this  fever,  namely, 
2c7iat  means  shall  he  employed  to  sustain  heart  powei\  or, 
as  is  sometimes  said,  the  vital  powers  of  the  patient? 

When  a  i)atient,  during  tin;  second  or  thii'd  week  of  the 
disease,  dies  from  cai)illary  bronchitis,  pulmonary  oedema, 
or  suddenly  passes  into  a  state  of  conui,  failure  of  heart 
power  is  the  real  cause  of  death. 

In  those  cases  in  which,  during  the  early  part  of  the 
fever,  you  have  been  comj)elled  to  resort  to  a  vigorous  anti- 
pyretic treatment,  during  the  third  week,  although  the 
temperature  may  not  rise  higher  than  ]oi  F..  th«'  ])ulse 
frequently  becomes  extremely  ferble,  and  reach<'S  140  per 
minute,  the  first  sound  of  the  ln'art  becomes  inaudible, 
muscular  tremors,  dry  tongue,  and  all  tiie  phenomena 
which  indicate  failure  of  vital  power  are  })resent.  Under 
such  circumstances  the  use  of  stimulants  seems  to  be 
urgently  demanded. 

There  are  a  few  sim])le  rules  wiiieh  may  guide  you  in  the 
administration  of  stimulants  in  this  fever. 


74  TYPHOID    FEVER. 

Plrst. — They  should  never  be  administered  indiscrimi- 
nately— that  is,  never  give  a  patient  stimulants  simply  be- 
cause he  has  typhoid  fever. 

Second. — When  there  is  reasonable  doubt  as  to  the  pro- 
priety of  giving  or  withholding  stimulants,  it  is  safer  to 
withhold  them,  at  least  until  the  signs  which  indicate  their 
use  become  more  marked. 

Third. — In  every  case,  but  especially  when  stimulants 
are  not  clearly  indicated,  watch  carefully  the  effect  of  the 
first  few  doses.  There  are  few  whose  experience  in  the 
treatment  of  typhoid  fever  is  such  as  to  enable  them  to 
positively  determine,  from  the  appearance  of  the  patient, 
when  the  administration  of  stimulants  should  be  com- 
menced. 

Should  you  commence  the  administration  of  stimulants, 
it  is  necessary  to  see  your  patient  every  two  hours,  and 
note  carefully  the  effect  produced.  If  you  find  the  tongue 
becoming  dry,  the  patient  more  restless,  the  delirium  more 
active,  the  temperature  ranging  higher,  and  the  pulse  more 
and  more  rapid,  you  may  be  certain  that  stimulants  are 
contra-indicated.  If,  on  the  other  hand,  the  pulse  becomes 
fuller  and  more  regular,  if  the  first  sound  of  the  heart  is 
more  distinctly  heard,  or,  if  it  has  been  absent,  it  has  re- 
turned, if  the  restlessness  and  delirium  are  less  marked,  the 
tongue  more  moist  and  the  patient  more  intelligent,  you 
may  be  certain  that  the  time  for  the  administration  of  stim- 
ulants has  arrived.  When  you  have  commenced  their  use, 
it  is  of  the  greatest  importance  that  you  administer  them 
at  stated  intervals,  especially  during  the  night. 

In  a  severe  case  of  typhoid  fever,  a  free  administration  of 
stimulants,  just  at  a  critical  period  (which  may  not  last 
more  than  twenty-four  hours),  will  often  be  followed  by  a 
refreshing  sleep,  and  your  patient  may  rapidly  pass  from 
an  apparently  hopeless  condition  to  one  of  convalescence. 

The  tliird  important  thing  to  be  accomplished  in  the 
management  of  typhoid  fever  patients  is  the  maintenance  of 
nutrition.  You  must  bear  in  mind  that  the  primary  and 
principal  effects  of  the  typhoid  poison  are  manifested  in  the 
changes  which  take  place  in  the  lymphatics  of  the  gastro- 


TKKATMKNT.  /•> 

intestinal  tract.  Expt'iiriicf  has  tau<:;lit  us  that  th<'  cnfee- 
bI«*in»Mit  of  tht'  (lint'stivc  and  assiiiiihitivc  ])()\vi'rs,  duo  to 
thcst^  ulauduhir  chaiiLCt's.  whicli  air  luaiiirt'st  from  the  Vfiy 
coniiUfiicciiK'iit  of  thi'  ['<-vr\\  irn(h'is  thi' dig«'stiun  of  solid 
food  iiii))ossil)lt'.  and  for  :i  lon.^  tiino  it,  lias  bcm  the  nilf  of 
the  profession  to  uUow  typhoid  fever  patients  only  rupiid 
food. 

There  lias  been,  and  still  is,  gn^at  diversity  of  opinion  in 
regard  to  the  special  articles  of  diet  In-st  suited  to  this  class 
of  patients.  Most  medical  writers  and  i)ractitioners  claim 
that  beef-tea  is  the  proi)er  diet  for  fever  ]>ati»'nrs  ;  coiisf- 
quently  it  is  the  rule  to  pour  into  these  enfeebled  stomachs 
a  decoction  of  beef  in  such  quantities  as  a  healthy  stomach 
could  hardly  tolerate,  and  which,  in  itself,  has  little  or  no 
nutritive  element. 

Others  claim  that  gruels  are  far  superior  to  animal  broths, 
and  advocate  the  feeding  of  fever  patients  with  grurl  made 
of  barley  and  other  farinaceous  substances,  to  the  exclusion 
of  every  other  article  of  diet ;  yet  gruels  furnish  few  ele- 
ments essential  to  the  nourishment  of  a  physical  organiza- 
tion struggling  against  a  subtle  poison,  and  rapidlj'  wasting 
with  a  burning  fever,  and  starvation  is  the  necessary  result 
of  a  restriction  to  gruel  diet. 

There  is  no  disease  in  whicli  a  waste  of  all  the  tissu<'s  of 
the  body  goes  on  so  ra])idly  as  in  typhoid  fever  ;  and  milk 
is  an  article  of  diet  which  furnishes  the  elements  of  nutri- 
tion necessary  to  repair  this  ia]»id  waste,  and  there  arc  not 
the  objections  to  its  use  which  there  are  against  animal 
broths  and  gruels.  Although  there  have  been,  and  still  arc, 
in  some  quarters,  strong  objections  against  its  use  as  an  aiti- 
cle  of  diet  in  fevers,  recently  it  has  been  regarded  with 
more  favor,  and  those  who  have  had  most  extended  oi)i)or- 
tunitics  for  testing  its  nutritive  qualities  have  come  to  regard 
it  as  the  only  article  nH  diet  required  by  tyjthoid  patients. 
In  it  we  not  only  find  all  the  elements  required  for  re]iairing 
tin*  rapidly  wasting  tissues,  but  they  are  in  a  condition  to 
be  mo>t  readily  assimilated  by  the  enfeebled  digestive  ap- 
paratus. 

In  Older  to  make  the  milk  more  digestible,  it  may  b<.'  di- 


76  TYPHOID    FEVER. 

luted  with  lime-water.  The  lime-water  is  an  antiseptic,  and 
allays  irritability  of  the  stomach  and  intestines.  The  quan- 
tity of  milk  is  not  limited  ;  the  patient  may  take  all  his 
stomach  will  digest — usually  patients  will  take  from  four 
to  six  quarts  in  the  twenty-four  hours. 

After  the  patient  has  passed  into  the  fourth  week  of  the 
disease,  you  may  find  it  necessary  to  administer  cream  and 
the  yolk  of  eggs  in  connection  with  the  milk. 

Having  considered  the  three  most  important  things  to  be 
accomplished  in  the  general  management  of  tyjohoid  fever, 
I  now  come  to  the  treatment  of  the  accidents  of  the  disease. 

DiARRiKEA. — I  have  told  you  that  diarrhoea  is  one  of  the 
common  symptoms  of  this  fever ;  but  it  is  one  of  which 
medical  writers  have  taken  sj^ecial  notice,  and  for  the  relief 
of  which  different  means  have  been  employed. 

Let  us  for  a  moment  notice  the  chain  of  phenomena  of 
which  diarrhoea  is  a  link.  The  poison  which  produces  this 
fever  unquestionably  has  a  specific  action  upon  the  intes- 
tinal glands  and  lymphatics.  It  is  here  that  we  find  the 
characteristic  lesions  of  the  disease,  and  it  is  scarcely  ques- 
tioned that  the  typhoid  poison,  to  a  great  extent,  gains 
entrance  to  the  system  through  these  glands  and  lymphat- 
ics, and  here  produces  the  primary  irritation.  Following 
the  irritation  and  inflammation  of  the  follicles,  other  por- 
tions of  the  mucous  membrane  become  involved,  and  we 
have  a  catarrhal  inflammation  of  the  mucous  membrane  of 
the  intestinal  tract.  The  necessary  consequence  of  this  is 
a  diarrhoeal  discharge.  Is  this  diarrhoea  to  eliminate  the 
fever  poison?  Certainly  not.  It  is  simply  an  indication 
that  these  intestinal  changes  are  going  on  ;  it  is  not  due 
to  the  elimination  of  the  typhoid  fever  poison,  but  to  the 
inflammation  which  the  fever  poison  has  excited  in  the 
intestinal  glands,  and  the  subsequent  intestinal  catarrh. 
When  the  diarrhoea  is  present  in  the  earlier  period  of  the 
disease,  it  is  better  to  let  it  alone.  The  question  may  be 
asked,  will  it  not  exhaust  the  patient  '\  During  the  earlier 
period  of  the  fever  (the  first  and  second  week)  the  danger 
is  very  slight.  It  has  been  proposed  to  treat  this  diarrhoea, 
which  makes  its  appearance  early  in  the  disease,  with  alka- 


TIIKATMKXT.  77 

lie?!,  bi^mntli,  p<']isin,  etc  II  is  chiimt'd,  if  those  roni<'(li«'s 
beadiuiiiistfrcd,  di:inh«i'a  can  !»<•  luwcntrd.  or,  if  it  alnnidy 
exists,  tliat  it  can  be  controlled.  Tln^oreticiilly,  I  sw  no 
reason  for  cmiiloying  alkaline  ivinedi(>s,  for  tin- dian-liovil 
dischar<;-es  aiv  always  strongly  alkaline,  and,  from  clinical 
observation.  I  am  convinced  that  bismuth,  j)epsin,  etc., 
have  little  or  no  effect  eitlier  in  (lontrollin^  th(^  diarrhd'a 
or  in  ])ivventinn:  the  intestinal  changes  which  ])roducc  it. 
When  diarrlura  commiMices  lair  in  the  disease  (diirinf;  the 
latter  part  of  the  third,  or  during  the  fourth  wcM'k  of 
the  fever),  it  is  of  a  very  different  character  from  that 
which  occurs  during  the  first  and  second  weeks.  Ulcera- 
tion of  the  intestinal  glands,  and  perhaps  sloughing,  has 
been  establi<;hed,  and,  in  addition  to  the  extensive  local 
changes,  there  is  a  septic  element  Avhich  enters  into  the 
causation  of  the  diarrhoea  at  this  stage.  Besides,  the  in- 
creased peristaltic  action  of  the  intestines,  which  attends 
the  diarrhoea,  favors  an  extension  of  the  inflammatory  ])ro- 
cesses  to  the  peritoneum,  especially  that  portion  which 
covers  the  intestine,  which  corresponds  to  Peyer's  patches. 
In  view  of  these  facts,  the  diarrhoea  should  be  arrested  or 
held  in  check.  For  the  accomplishment  of  this,  there  is 
but  one  remedy  which  can  be  relied  upon— that  is,  opium. 
My  experience  is  against  the  use  of  astringents.  If  o])ium 
will  not  arrest  it,  you  may  expect  little  aid  from  astringents 
combined  with  o])ium  as  they  are  usually  administeivd. 

The  use  of  opium  is  objected  to  by  some,  who  claim  that 
it  diminishes  the  power  of  the  heart's  action;  bur  in  this 
disease,  when  administered  in  small  doses,  it  seems  to  me 
to  increase  rather  than  diminish  the  heart-power.  It  is  ac- 
knowledged that  0])ium,  more  tlian  any  other  drug,  arrests 
the  peristaltic  action  of  the  intestines  ;  and  that  is  what  we 
wish  to  accomplish  when  diarrlupa  is  jtrescnt  during  the 
third  and  fourth  week  of  typhoid  fever. 

Tymiwxitis. — You  will  recollect  that  the  tympanitis, 
which  is  sometimes  so  troubh-.some  a  symptom  in  t3i)hoid 
lever,  is  due  to  gaseous  distention  of  the  intestines.  Some 
assert  that  this  gaseous  accumulation  is  due  to  ft-rmentative 
processes  going  on  in  the  inr''-.tin''<  :  consequently  that  the 


78  TYPHOID    FEVER. 

use  of  antiseptic  remedies  is  indicated,  sncli  as  muriatic 
acid,  chlorate  of  potash,  pepsin,  etc.  When  this  has  proved 
a  distressing  symptom,  I  have  usually  found  relief  to  be 
obtained  by  the  application  of  turpentine  stupes  to  tlie  ab- 
domen. Some  claim  that  if  turpentine  be  administered 
internally,  from  the  beginning  to  the  end  of  typhoid  fever, 
that  tj^mpanitis  and  the  intestinal  changes  which  lead  to  it 
and  to  the  diarrhcea  are  much  less  severe.  I  am  confident 
that  the  turpentine  treatment,  as  it  is  called,  does  not  have 
the  controlling  influence  over  this  fever  which  has  been 
claimed  for  it ;  but  I  am  also  certain  that  it  is  our  most 
reliable  agent  for  the  relief  of  the  tympanitis. 

Intestinal  Hemorrhage. — Hemorrhage  from  the  bow- 
els in  tjT-phoid  fever  (as  I  have  already  stated)  is  a  serious 
accident,  and  mn,y  cause  death  by  producing  a  fatal  ex- 
haustion. 

When  it  occurs  earl 3^  in  the  fever,  usuall}^  it  requires  no 
treatment ;  but  when  it  occurs  during  the  third  or  fourth 
week,  or  after  convalescence  is  apparently  fully  established, 
it  must  be  arrested  as  promptly  as  possible. 

The  occurrence  of  severe  intestinal  hemorrhages  may 
sometimes  be  prevented  by  keeping  the  patient  in  bed.  A 
typhoid  fever  patient  should  not  be  allowed  to  get  out  of 
bed  from  the  beginning  of  the  attack  until  convalescence  is 
fully  established.  Especically  is  this  of  importance  if  the 
case  is  a  severe  one,  and  attended  by  symptoms  that  indi- 
cate extensive  intestinal  lesions. 

When  hemorrhage  from  the  intestines  does  occur  during 
the  third  or  fourth  week  of  the  fever,  at  once  semi-narcotize 
your  patient  by  the  administration  of  opium  in  small  doses 
at  short  intervals.  Absolute  rest  of  the  body  must  be  in- 
sisted on,  the  patient  must  not  be  turned  on  the  side  or 
moved  in  bed,  and  an  ice-bag  should  be  applied  over  the 
abdomen.  I  doubt  if  any  good  results  can  be  accomplished 
by  the  use  of  astringents,  either  by  enemata  or  by  the 
mouth,  as  it  is  not  known  that  they  even  reach  the  seat  of 
the  hemorrhage,  although  gallic  acid  and  the  persulphate 
of  iron  are  usually  recommended  in  cases  of  intestinal  hem- 
orrhage occurring  in  typhoid  fever.     If  the  hemorrhage  is 


TltKATMKN'T.  7'J 

profiiso,  if  niny  bo  nocossary  to  k»'<'p  your  jjatlt'iit  undtT  tlie 
iiitliit'iicc  of  the  o])ium  for  :i  \v('«'k  or  ten  days  ;  in  sucli  cases 
tho  internal  use  of  turpentine  in  connection  willi  the  oj)iuiu 
will  be  found  of  service. 

Peritomtis. — When  perforation  of  the  intestine  occurs, 
the  case  may  be  regarded  as  hopeless ;  death  takes  place 
usually  witliin  twenty-four  hours:  death  occurs  as  the 
result  of  geiu-ral  ])eritonitis  ;  no  plan  of  treatment  avails 
anything.  If  the  ]ieritonitis  occurs  without  perforation, 
from  the  extension  of  the  inflammatory  process  from  the 
intestinal  ulcers  to  the  ])eritoneuni,  by  bringing  your 
patient  rapidly  into  a  state  of  semi-narcotism  and  holding 
him  there  for  live  or  six  days,  you  may  prevent  the  ex- 
tension of  the  peritonitis  and  thus  save  life.  Such  a  case 
you  are  to  treat  in  every  respect  as  one  of  localized  perito- 
nitis. 

After  recoveiy  from  an  intestinal  hemorrhage  or  a  local- 
ized peritonitis  in  typhoid  fever,  be  exceedingly  careful 
about  the  administration  of  cathartics  or  enemata ;  either 
may  jeopardize  the  life  of  your  patient.  The  bowels  will 
move  spontaneously  after  a  time,  even  though  the  use  of 
opium  be  continued,  and  no  harm  will  follow  should  two  or 
three  weeks  pass  without  a  movement  from  them. 

When  the  stomach  is  irritable,  the  hy}>odermic  injection 
of  morphine  is  preferable  to  opium  administered  by  the 
mouth.  This  is  given  in  sufficiently  large  quantities  to 
paralyze  the  peristaltic  movement  of  the  intestines. 

Bkoxciiitis. — I  have  aheady  stated  that  catarrh  of  the 
larger  bronchial  tubes  is  ])resent  in  all  severe  cases  of 
tyi)hoid  fever.  Xo  sptvial  treatment  is  required  for  its 
management  ;  but.  if  tlie  bronchitis  becomes  cajullary, 
great  relief  will  be  obtained  from  the  ap]>lication  of  dry 
cups  to  the  chest  and  the  internal  administration  of  car- 
bonate of  ammonia.  Vapor  inhalations  will  also  be  found 
of  service  in  severe  cases. 

Pneumonia. — The  pneumonia  which  complicates  typlioid 
fever  in  nearly  every  case  is  lobular  in  character.  The 
signs  which  indicate  its  occurrence  are  sudden  rise  of  tem- 
perature, increased  frequency  of  respiiation,  and  the  physi- 


80  TYPHOID    FEVEK. 

cal  signs  of  localized  pulmonary  consolidation  ;  congh  and 
expectoration  are  rarely  present. 

Its  occurrence  is  always  an  indication  tliat  stimulants 
should  be  administered.  If  they  are  being  administered, 
they  should  be  increased  in  quantit}^  To  prevent  or  relieve 
tlie  hypostatic  congestion  of  other  portions  of  the  lung, 
which  frequently  accompanies  pneumonic  development,  the 
heart-power  must  be  increased,  and  the  position  of  the 
patient  changed. 

Laryi^^gitis. — For  the  relief  of  the  laryngitis  which  occa- 
sionally complicates  typhoid  fever,  a  small  blister  may  be 
applied  on  either  side  below  the  angle  of  the  Jaw,  and  the 
whole  neck  enveloped  in  a  poultice.  If  these  measures 
fail,  and  suffocation  appears  imminent,  tracheotomy  should 
be  resorted  to  without  delay. 

Subacute  gastric  catarrh,  occurring  as  a  complication 
during  convalescence  from  the  fever,  can  only  be  managed 
successfully  by  giving  the  stomach  rest  as  far  as  possi- 
ble, restricting  the  diet  to  a  single  tablespoonful  of  milk 
at  a  time,  and  applying  hot  fomentations  over  the  epigas- 
trium. 

Bed-sores. — The  severer  forms  of  bed-sores  are  the  most 
intractable  complications  we  have  to  combat.  Fortunately, 
the  severer  forms  are  much  less  frequently  met  with  under 
the  more  recent  plan  of  treatment ;  and,  if  they  do  occur, 
they  are  superficial  and  limited  to  small  spots.  Scrupulous 
cleanliness  is  one  of  the  principal  means  for  preventing 
their  development.  So  long  as  there  are  no  erosions,  the 
parts  should  be  frequently  bathed  in  spirits  of  camphor, 
and  the  points  of  attack  should  be  relieved  from  all  pres- 
sure. If  the  sores  penetrate  the  integument,  they  should 
be  frequently  washed  with  a  weak  solution  of  carbolic 
acid,  or  brushed  over  with  equal  parts  of  balsam  peru  and 
balsam  copaiva  and  afterwards  covered  with  dry  lint  or 
lint  covered  with  vaseline. 

The  most  unfavorable  cases  are  those  in  which  the  point 
of  pressure  caused  by  the  weight  of  the  body  becomes  gan- 
grenous. In  such  cases,  by  some  a  continuous  warm  bath 
is  recommended.     As  soon  as  sloughing  takes  place,  and 


■rilKATMKXT.  81 

tlu'  ]»;uts  scpunitc,  tlu^v  slu)iiM  Ix'  drcsst'd  witli   lint  siitii 
luted  with  bals^aiii  ul*  ]K'ni  and  caiholic  acid. 

As  has  been  already  stated,  dianluL'a  is  usually  })r»'S(!UL 
in  the  early  i)eri()d  of  this  fever;  but  sometimes  there  is 
e<»nsti})atioii.  The  ijuestion  arises,  is  tlie  adnuuistration  of 
cathartics  ever  admissible  in  typhoid  fever  i  If  so,  what 
cathartic  shall  be  employed  i  There  is  great  diversity  of 
o])ini<)ii  ui>()ii  these  points.  One  recommends  the  adminis- 
tration of  rliui)arb,  another  advises  alkaline  cathartics,  and 
another  would  give  calomel. 

Quite  diverse  views  are  still  held  in  regard  to  what  the 
answer  to  this  question  should  be.  liecently,  certain 
observers  of  extended  experience  have  claimed  that  there 
is  sufficient  reason  for  the  belief  that  a  portion  of  the 
typhoid  poison  lodged  in  tlie  alimentary  tract  may  be 
expelled  by  the  timely  administration  of  cathartics,  and 
thus  the  severity  of  the  fever  be  mitigated  and  its  duration 
shortened.  Recent  German  writers  claim  that  calomel, 
concerning  the  favorable  action  of  which  in  this  fever  so 
much  has  been  said  and  written,  acts  beneficially  only  as  a 
cathartic.  Those  who  favor  the  administiation  of  cathar- 
tics recommend  their  use  uuunly  during  the  first  week  of 
the  disease. 

On  the  other  hand,  eqnall}'  competent  observers  maintain 
that  the  intestinal  changes  are  augmented,  and  rendered 
more  extensive  by  the  action  of  cathartics  ;  that  the  normal 
course  of  the  fever  is  interfered  with  ;  and  that  in  a  largt^ 
proportion  of  cases  where  intestinal  and  jxMitoncal  compli- 
cations occur,  hypercatharsis  has  been  induced  at  an  early 
period  of  the  fever  by  the  administration  of  cathartics  for 
the  purpose  of  shortening  its  duration.  My  own  experience 
leads  me  to  exercise  the  greatest  caution  in  the  administra- 
tion of  cathartics  in  an}'  stage  of  this  fever.  I  am  conlident 
that  the  routine  practice  of  administering  purgative  medi- 
cines in  tlie  early  stage  of  typhoid  fever  can  only  be  fol- 
lowed by  a  threefold  injury  : 

i'V/'.sY. — The  patient  is  weakened. 

Second. — The  local  intestinal  lesions  aiv  increased. 

Tliird. — Perforating  peritonitis  is  more  liable  to  occur. 
0 


82  TYPHOID    FEVER. 

The  administration  of  cathartics  as  an  oliminative  pro- 
cedure has  neither  reason  nor  experience  to  sustain  it. 

Before  speaking  of  the  management  of  the  convalescence 
of  typhoid  fever,  I  will  make  a  few  general  remarks  on  the 
use  of  anodynes  for  the  relief  of  certain  troublesome  ner- 
vous phenomena. 

I  have  stated  to  you  that  among  the  earliest,  most  fre- 
quent, and  often  most  prominent  nervous  symptoms  in  this 
fever  is  headache,  but  it  is  seldom  very  violent  or  of  long 
continuance. 

Should  it  be  severe,  not  readily  relieved  by  fomenting  the 
forehead  and  temples  with  warm  water,  or  should  it  give 
place  to  active  delirium,  and  other  severe  nervous  disturb- 
ances, the  question  presents  itself,  shall  anodynes  be 
administered  ?  If  you  decide  to  use  them,  the  most  reliable 
of  this  class  of  remedies  is  opium. 

Usually,  the  condition  of  the  pupil  of  the  eye  will  serve 
to  indicate  to  us  whether  opium  shall  or  shall  not  be 
administered.  A  contracted  or  "pin-hole"  pupil  maybe 
considered  to  contra-indicate  its  use,  though  there  are  exceiD- 
tional  cases  in  which  opium  acts  favorably,  notwithstanding 
this  condition  of  the  pupil. 

Opium  should  be  given  with  great  caution  whenever 
signs  of  cyanosis  are  present.  In  all  cases  of  typhoid  fever, 
it  is  safer  to  administer  opium  in  small  and  repeated  doses 
than  to  venture  upon  the  administration  of  one  large  dose. 

There  are  other  anodynes  which  you  will  sometimes  find 
of  service,  such  as  hyoscyamus,  chloral,  and  the  bromides. 
I  would  caution  you  against  administering  too  large  doses 
of  chloral  ;  the  desired  effect  can  generally  be  produced  by 
ten  or  fifteen  grains.  If  the  first  dose  fails  to  relieve,  a  sec- 
ond may  be  administered  at  the  expiration  of  two  hours. 
This  remedy  is  said  to  have  a  special  value  in  quieting  the 
active  delirium,  which  is  sometimes  so  troublesome,  but  my 
own  experience  in  its  use  has  not  been  favorable.  When 
anodynes  have  failed  to  give  relief  to  typhoid  fever 
patients,  who  have  been  delirious  aud  somnolent  for  days, 
they  will  sometimes  become  quiet  and  fall  asleep  immedi- 
ately after  the  free  administration  of   stimulants.     Those 


TUKATMKXT.  8;} 

('asi>s  in  w  hicli  |  In-  nervous  symptoms  iirc  din-  to  an  an.-rmic 
condition  of  tiic  hiain,  associafcd  with  a  ufak  lirmt  and  a 
tlaggiiii;-  riicnlation.  ar(>  mosf  lik<'ly  to  Ix'  iK'nclilfd  hy  tin; 
use  of  stimulants.  In  iliosr  cjisrs  in  wliidi  sul)sultus 
becomes  vory  maikrd  mid  tlici-c  is  a  gcufral  tn-nioi',  jacti- 
tation, and  rcstlcssiit'ss,  1  Ikuc  seen  most  lia})])y  ellrcts  jiro- 
duced  by  the  use  of  liyjuxlcrmic  injections  of  sulpliuiic 
etlier.  1  \\(»uld  use,  as  an  average  (|ii;iiiiiiy.  fom- diiiclims 
given  in  injections  of  one  drachm  eacli,  in  dill'erent  ])laces. 

Tile  sanu'  watcid'ul  care  sliould  l)e  tal-ten  of  a  ty])hoid 
fev<'r  ]iatient  during  convalescence  as  dui-ing  tlie  active 
j)eriod  of  tlie  fever. 

Tlie  numl)er  of  tyjdioid  patients  who  die  duiing  convales- 
ceiu'e  is  ])roportionally  large.  Frequently  this  is  due  to 
the  fact  tliat  tlie  })hysician  has  laid  down  no  sti-ict  rules  to 
be  observed  as  to  diet  and  ex(^rcise,  and  frequently  from 
the  non-observance  of  such  rulers  when  tliey  liave  been  given. 

The  diet  of  fever  patients  during  this  period  sliould  be 
carefully  watched.  Allow  your  patient  to  eat  frecpieiitly, 
but  only  small  quantities  of  food  should  be  taken  at  a  time, 
so  that  the  gastric  juice  secreted  by  the  enfeebled  stomach 
may  be  sufficient  for  its  complete  digestion.  All  indigesti- 
ble articles  of  food,  and  those  which  fuinisli  a  large  amount 
of  waste,  slnmld  be  stiictly  forbidden.  An  ap])arently 
insignilicant  disturbance  of  tlie  stomach,  a  slight  vonnting, 
or  a  moderate  diarrha?a  occurring  during  the  period  of  con- 
valescence sliould  be  regarded  as  dangei'ous,  for  any  ones  of 
these  may  induce  a  subacutt^  gastritis,  or  lead  to  intestinal 
])erforation  and  a  fatal  ])i'ritonitis.  It  is  o])vious  that  while 
the  intestinal  ulcers  are  healing,  much  misciiief  may  be 
done  by  imjnoper  diet. 

Notwithstanding  the  cravings  of  the  ]Kitient's  a])petite, 
the  diet  must  be  restricted  to  such  articles  as  milk,  cream, 
gruels,  jellies,  and  aninuil  broths.  Solid  food  must  be 
strictly  forbidden,  especially  meats,  vegetables,  and  fruits. 
Tf  diarrh(pa  is  ]u-esent  duiing  convalescence  it  is  far  safer  to 
restrict  the  patient  to  milk  and  cream.  All  exercise,  exce])t 
simply  walking  around  the  sick-room,  should  be  proliibited. 
I  have  had  iiatieiits  con\alescing  from  tyjthoid  fever  sink 


84  TYPHOID    FEVER. 

rapidly  after  a  long  ride,  or  after  indulging  in  some  violent 
and  fatiguing  physical  exercise.  It  is  of  the  greatest  impor- 
tance that  this  class  of  patients  should  keep  in  the  recum- 
bent or  semi-recumbent  posture  until  the  cicatrization  of 
the  intestinal  ulcers  is  completed,  which  in  some  instances 
does  not  take  place  for  two  or  three  weeks  after  convales- 
cence is  w^ell  established.  If  convalescence  is  slow,  small 
doses  of  quinine,  iron,  and  cod-liver  oil  are  of  service.  They 
should  be  given  after  the  patient  has  taken  food. 

When,  during  the  period  of  convalescence,  diarrhoea  is 
persistent,  the  patient  should  be  kept  in  bed,  and  some  of 
the  vegetable  astringents,  such  as  catechu,  hgematoxylon, 
may  be  employed. 

In  many  cases  it  is  important  that  you  should  take  the 
evening  temperature  for  at  least  two  weeks  after  the  com- 
mencement of  convalescence,  for  by  its  range  you  will  be 
able  the  more  accurately  to  determine  the  exact  condition 
of  your  patient. 

When  convalescence  is  delayed,  so  that  at  the  end  of 
four  or  five  weeks  the  patient  has  not  regained  strength, 
change  of  air  is  indicated. 


LECTURE   VIII. 


YELLOW  FEVER. 
Morh  id  Anatomy.  — Etiology.  — Symptoms. 

TIII^?  morning  I  will  commence  the  history  of  the  second 
in  the  list  of  miasmatic-contagions  fevers,  namely,  Yellow 
Fever, 

This  fever  has  received  its  name  from  a  yellow  discolora- 
tion of  the  skin,  which  is  a  part  of  its  clinical  history. 

The  term,  yellow  fever ^  has  been  generally  adopted  b}' 
American,  English,  French,  and  German  writers,  and  it  is 
not  necessary-  to  mention  the  long  list  of  obsolete  names 
which  have  been  applied  to  this  disease  by  different  writers, 

^MoUBiD  AxATOMY. — We  find  tliat  the  anatomical  changes 
whicli  take  place  in  the  diffen-nt  organs  and  tissues  of  tlie 
body  during  the  course  of  this  fever,  in  some  respects  are 
similar  to  those  which  occur  in  miasmatic  and  contagious 
fevers,  allying  the  disease  more  or  less  nearly  to  eacli  of 
these  classes  of  fever. 

Althougli  these  different  types  of  fever  have  many  points 
of  resemblance  in  their  anatomical  lesions,  as  well  as  in 
their  general  history,  each  has  its  own  distinguishing  char- 
acteristics which  mark  it  as  a  distinct  and  specific  disease. 

The  characteristic  lesion  (if  we  may  so  call  it)  of  yellow 
fever  is  to  be  found  in  the  liver.  This  organ  is  not  much 
increased  in  size,  but  there  is  a  striking  and  uniform  change 
in  its  color,     Sometini'*^  it  i^  of  the  color  of  fresh  butter, 


86  YELLOW   FEVEE. 

sometimes  of  a  mustard  color,  and  sometimes  tlie  color  of 
coffee  and  milk,  or  cliocolate  color.  In  most  instances  this 
change  occurs  throughout  the  entire  organ ;  occasionally, 
it  is  confined  to  one  lobe,  or  to  a  small  portion  of  a  lobe. 
With  this  change  in  color  there  is  a  diminution  in  the  quan- 
tity of  blood  in  the  liver,  so  that  it  contains  less  blood  than 
normal.  It  has  a  dry  appearance,  is  softer  than  norma], 
breaking  down  readily  on  firm  pressure.  When  a  section  is 
placed  under  the  microscope,  it  will  be  seen  that  there  has 
been  infiltration  of  the  hepatic  cells  with  oil-globules.  In 
fact,  all  of  the  liver  cells  are  more  or  less  filled  with  oil-glob- 
ules. Sometimes  the  change  is  a  granular  one,  the  nuclei 
of  the  cells  have  disappeared,  or  become  obscured  ;  in  other 
instances,  the  entire  liver  cells  have  filled  with  large  oil-glob- 
ules, but  the  form  of  the  cells  has  not  changed. 

This  change  lias  received  the  name  of  acute  fatty  degen- 
eration. In  its  gross  appearance,  as  well  as  in  its  minute 
anatomical  changes,  the  liver  resembles  the  fatty  degenera- 
tion of  the  liver  of  rum-drinkers.  Besides  this,  there  is  no 
change  of  any  importance  observed  in  the  liver  in  yellow 
fever,  except  it  may  be  slight  extravasations  of  blood  upon 
its  surface,  rarely  in  its  substance. 

Mucous  Membrats^e-s. — You  will  find  the  mucous  mem- 
brane of  the  intestinal  track,  as  also  that  of  the  larynx,  the 
seat  of  a  more  or  less  severe  acute  catarrh.  The  vessels  of 
the  mucous  surfaces,  especially  the  veins,  will  present  a 
turgid  appearance  ;  and  so  intense  is  the  h^^perpemia  that  at 
points  they  will  present  a  varicose  appearance.  If  there 
is  a  uniform  congestion  throughout  the  entire  extent  of  the 
intestinal  track,  you  will  notice  here  and  there  little  blood 
extravasations  or  ecchymotic  spots.  The  whole  track  con- 
tains a  greater  or  less  quantity  of  fluid  blood.  Frequently 
the  mucous  membrane  of  the  stomach  is  found  thickened, 
reddened,  and  softened,  sometimes  with  quite  extensive 
blood  extravasations.  The  contents  of  the  stomach  corre- 
spond to  matters  vomited  during  life,  which  I  shall  more 
fully  describe  under  the  head  of  symptoms. 

Heart. — The  heart  is  soft  and  flabby,  ligliter  in  color 
than  normal,  and  will  be  found  to  have  undergone  degen- 


MolMUl)    ANATOMY.  87 

pvativf  clKiiiufS  similar  to  tliosc  wliicli  take  jOacc  in  ils 
imiscular  tissue  in  typhoid  fi'Vfi-.  Tlicsc  dianL^cs  iimloiiht- 
»'(lly  do  not  depend  nium  lii-li  l«iiiiieral  ni-i-,  for  a  very 
lii^i;h  renii>eiature  is  laicly  ])resent  in  yellow  fever.  The 
normal  outline  df  the  heart  is  lost,  and  it  breaks  down 
readily  on  lirm  prosure.  The  more  severe  the  f.v.-i-.  ami 
the  lon,ii:er  ils  duration,  the  more  extensive  will  lie  the 
parenchymatous  deueneratioii.  The  ])ericardium  usually 
contains  one  oi' i  uo  ounces  of  blood-staiin'fl  sei'uin.  Par- 
tially ori;ani/,ed  clots  are  found  in  tlie  heart  cavities  ;  these 
often  e.xleiid  for  some  distance  into  tlh'  vc^ssels.  The}'  are 
the  residt  of  a  slowing-  of  the  circulation  from  feel)leness 
of  the  heart  })ower,  and,  in  most  instances,  are  J'ormed  just 
prior  to  death,  although  they  are  not  tlie  cause  of  death. 

Lungs, — Usually  the  lungs  are  the  seat  of  hemorrhagic 
infarctions.  In  fact,  you  will  rarely  make  ati  auto})sy  ui)on 
one  who  has  died  of  yellow  fever  without  hndiiig  iid'arctions 
in  the  lungs,  and  sometimes  they  w^ill  be  quite  numerous. 
Diffused  pulmonary  apoplexies  often  occur,  wdiicli  may  in- 
volve a  large  portion  of  a  lobe.  Under  such  circumstances 
the  lung  tissue  will  be  broken  down  and  occupied  by  large 
blood-clots.  Spots  of  ecchymosis  will  also  be  found  under 
the  pulmonary  and  costal  pleura. 

KiDXEVs. — The  kidneys  are  always  more  or  less  increased 
in  size.  This  increase  is  due  to  swelling  of  the  cortical  sub- 
stance, which  is  the  seat  of  a  more  or  less  extensive  fatty 
metamorphosis.  It  is  a  true  parenchymatous  nephritis,  in 
which  the  fatty  stage  is  very  rapidly  reached.  You  will 
find  the  uriniferous  tubules  crowded  with  oil-globules  ;  in 
some  places  the  tubes  are  denuded  of  epithelium  ;  in  other 
places  they  are  filled  with  broken-down  e])itlielium,  which 
is  undergoing  a  fatty  and  granular  change.  The  pelvis  of 
the  kidneys  is  frequently  tln^  seat  of  acute  catarrh,  and  evi- 
dences of  catarrhal  iiiHammation  may  be  found  along  tin; 
ureters  and  in  the  blad<h'r.  The  mucous  membrane  of  the 
l)ladder  will  also  be  found  to  be  the  seat  of  jiunctate  ecchy- 
moses.  In  fact,  in  all  th<'  mucous  surfaces  of  the  body 
large  and  snudl  tM'clninoses  are  found. 

BiiAix. — The  brain  and  its  membranes,  as  well  as  the  spi- 


88  YELLOW   FEVER, 

iial  cord,  present  no  marked  cliange.  They  are  often  hyper- 
{vniic,  and  are  frequently  the  seat  of  punctate  extravasation. 

Spleen.— The  spleen  is  but  slightly,  if  at  all  enlarged, 
is  of  a  darker  color  and  of  a  softer  consistency  than  nor- 
mal. 

Skin". — The  skin  varies  in  color  from  a  bright  yellow  to  a 
dark  orange.  It  may  be  the  seat  of  eccliymoses  or  of  large 
extravasations. 

Blood. — There  is  one  other  important  lesion  of  this  dis- 
ease, namely,  the  changes  which  take  place  in  the  blood. 
There  is  nothing  characteristic  about  them  ;  they  are  simi- 
lar in  character  to  those  which  take  place  in  the  blood 
in  typhus  and  typhoid  fever,  although  more  extensive  than 
in  either.  The  blood  coagulates  much  less  rapidly  and 
much  less  perfectly  than  normal  blood.  This  loss  of  coagu- 
lating power  may  be  due  to  a  diminution  in  its  fibrin,  or  to 
a  loss  of  coagulating  power  in  the  fibrin.  These  changes 
were  noticed  by  the  earliest  writers  on  this  disease.  The 
blood  is  changed  in  color,  being  darker  than  healthy  blood. 
The  blood-globules,  instead  of  retaining  their  rounded  out- 
line, have  their  edges  serrated  and  break  down.  There  is 
no  free  pigment,  such  as  is  found  in  the  different  forms  of 
malarial  fever. 

Blood  taken  from  yellow  fever  patients  rapidly  undergoes 
ammoniacal  changes. 

Some  of  the  pathological  lesions  of  ^^ellow  fever  very 
closely  resemble  those  of  relapsing  fever.  In  both  we  find 
similar  changes  in  the  blood  and  a  tendency  to  hemorrhages. 

Etiology. — To  the  student  of  the  literature  of  this  dis- 
ease, there  is  no  part  of  its  history  so  uncertain  or  so  con- 
fusing as  that  of  its  etiology.  Equally  competent  observers 
widely  difi'er,  and  often  hold  diametrically  opposite  views 
in  regard  to  it. 

In  our  own  city,  some  very  bitter  monographs  have  been 
written  by  medical  men  holding  antagonistic  views  in  regard 
to  the  causation  of  yellow  fever. 

I  shall  endeavor  briefly  to  state  well-authenticated  facts 
concerning  its  causation,  as  far  as  possible  making  no 
mention  of  mere  theories. 


KTloI-OdV.  89 

I'lultT  tills  lit'iul,  tilt'  lirsl"  question  tli;i(  ]»i-('Srnts  itself  is, 
Jn  wliiit  localities  doi's  tli.-  fi-vi-i-  pifvaii  '. 

It  is  raivly  iin-f  with  iioitli  of  -!<»'  north  latitude,  or 
south  of  20'  sonth  latitudr.  It  })r('vails  niurh  more  fre- 
quently on  the  wrsti'iii  than  on  the  eastern  liernis])here, 
and  in  cfitain  jxntions  of  Kuro])e  and  Ann-lira  than  in 
Africa.  It  is  almost  exclusively  conliiK'd  to  conmiercial 
s«^aports,  and  is  sometimes  circumsciihed  to  v(My  nanow 
limits  within  those  seaports.  A  certain  amount  of  moist- 
ure, either  on  the  surface  or  in  the  substance  of  the  soil, 
is  necessary  for  its  ])roduction.  There  must  also  ]i(>  present 
decaying  animal  and  vegetable  matter.  l-'or  tli'-  ]>i-oduc- 
tion  of  the  nuasm  which  causes  malarial  fevers  vegetable 
decomposition  is  sufficient,  but  for  the  development  of 
yellow  fever,  both  animal  and  vegetable  decomposition  is 
necessary.  A  high  temi)erature  is  necessary  to  its  develop- 
ment. The  average  temperature  for  the  twenty-four  hours 
must  be  above  77°  F. 

The  period  of  the  3'ear  during  which  yellow^  fever  prevails 
depends  upon  climate  and  temperature.  In  the  United 
States,  it  has  usually  appeared  in  July  or  August,  and  dis- 
appeared upon  the  first  frost.  The  great  epidemic  of 
yellow  fever  in  New  York  City,  in  1795,  began  early  in 
August,  and  disappeared  about  the  middle  of  Octo- 
ber. 

Undoubtedly,  this  fever  is  indigenous  in  certain  locali- 
ties. There  are  certain  seaports  along  our  southern  coasts, 
and  certain  islands  of  the  sea,  wdiere  it  is  developed  when- 
ever the  necessary  atmospheric  conditions  are  present. 
Especially  is  it  a  disease  of  hot  climates,  and,  in  localities 
that  are  subject  to  it,  it  is  more  likely  to  prevail  in  very 
waini  and  wet  than  in  cold  and  dry  seasons.  It  ma}^  be 
endemic  or  epidemic.  Sporadic  cases  are  of  rare  occur- 
rence, even  in  localities  where  it  is  indigenous.  Some  races 
more  than  others  are  subjects  of  this  fever.  The  African 
race  is  most  exem])t  from  it. 

A  prolonged  residence  in  a  district  where  yellow  fever  is 
indigenous  renders  an  individual  less  liable  to  contract  the 
fever.     Possibly  a  person  may  become  acclimated  to  the 


90  YELLOW   FEVER. 

disease.     Having  once  liad  the  disease  is  a  partial,  tliongli 
not  complete,  ])iotection  against  a  second  attack. 

North-westerly  winds  seem  to  arrest,  while  south-easterly 
winds  seem  to  favor  its  development.  In  other  words, 
when  south-easterly  winds  are  prevailing,  the  epidemic 
spreads  and  increases  in  severity,  while,  if  the  wind  changes 
to  the  north- w^est,  its  progress  is  arrested.  Whenever  the 
ttnnperature  falls  below  the  freezing  point,  no  matter  how 
pestiferous  a  region  may  have  been,  nothing  more  need  be 
feared  from  the  spread  of  the  disease. 

These  are  some  of  the  conditions  which  are  necessary  for 
the  development  and  spread  or  arrestation  of  yellow 
fever. 

Now,  the  question  arises,  What  is  the  nature  of  the 
poison  that  produces  the  fever  \  Is  it  a  miasm  or  a  conta- 
gion ?  There  can  be  no  question  but  that  it  is  a  poison  in 
many  respects  similar  to  that  of  typhoid  fever,  which  can 
be  conveyed  in  some  way  from  one  individual  to  another, 
or  rather  that,  when  certain  atmospheric  conditions  are 
present  in  connection  with  animal  and  vegetable  decom- 
position, the  introduction  of  the  specific  yellow  fever  poison 
is  followed  by  its  rapid  reproduction.  When  it  has  been 
so  reproduced,  it  may  be  received  into  the  human  system 
and  give  rise  to  morbid  processes,  attended  by  certain  clin- 
ical phenomena  wdiicli  are  characteristic  of  this  disease. 
Thus  far  chemical  and  microscopical  research  has  afforded 
no  positive  information  in  regard  to  the  nature  of  the  yel- 
low fever  poison,  but  there  can  be  no  question  as  to  the 
existence  of  such  a  distinct  and  specific  poison,  and  it 
w-ould  seem,  from  the  conditions  necessary  to  its  develop- 
ment and  the  manner  of  its  conveyance,  that  it  is  in  some 
respects  of  the  nature  of  a  miasm,  and  in  other  respects 
that  of  a  contagion.  You  may  have  yellow  fever,  remit- 
tent fever,  and  typhoid  fever,  all  prevailing  at  the  same 
time  in  a  locality,  yet  each  of  these  three  diseases  will  run 
its  individual  course,  and  no  one  will  lapse  into  another. 

The  question  now  comes  to  us.  Is  ydlow  fever  contagi- 
ous ?    There  are  three  leading  doctrines  upon  this  point. 

First— "TliQ  doctiine   of   unqualified  contagion,   which 


t:ti(»i,<m;v.  !•! 

attributes  to  tlio  disease  an  absolute  mikI  untiualilird  con- 
tagious eliaraeter. 

Secoti(L  -The  doctrine  of  non-cnjit(nji(ni,  wliicli  ninintains 
that  the  disease  is  never  transmitted  directly  Ironi  (Mie  per- 
son to  another. 

Third.— T\\e.  doctrine  of  conlingent  conlagioa,  wliicli 
teaches  that  the  disease  cannot  be  conveyed  from  one  indi- 
vidual to  another,  excej)!  in  a  yellow  fever  atmosi)here  ;  that 
is,  when  yellow  fever  is  prevailing  in  any  locality,  in  that 
locality  it  may  be  transmitted  from  one  ])erson  to  another. 

After  carefully  studying  the  recorded  observations  and 
weiu-hins;  the  statements  of  the  advocates  of  these  different 
doctrines,  I  can  unliesitatingly  state  to  you  that  the  majority 
of  those  who  have  had  the  most  extended  opportunities  for 
studying  this  disease,  deny  its  contagious  character,  and 
very  strongly  advocate  tlie  doctrine  of  non-contagion. 

Some  German  writers  claim  that  the  germ  in  yellow 
fever,  as  in  typhoid  fever,  cannot  be  conveyed  directly  from 
the  sick  to  the  health}',  but  that  it  must  first  be  deposited 
in  decom])Osing  animal  and  vegetable  matter,  and  that  wher- 
ever animal  and  vegetable  decomposition  is  going  on,  there 
are  present  the  conditions  necessary  for  the  rapid  rc^produc- 
tion  of  the  yellow  fever  germ.  One  tiling  is  certain,  that 
whenever  yellow  fever  prevails  as  an  epidemic,  there  is 
present  animal  and  vegetable  decomposition.  Th<^  disease 
prevails  only  where  men  are  crowded  together,  as  in  ships, 
and  around  the  docks  and  wharves  of  seaports,  and  in  the 
filth}'  streets  and  habitations  of  such  localities. 

In  some  few  instances,  evidence  exists  that  yellow  fever 
breaking  ont  in  the  hold  of  a  vessel  has  been  circumscribed 
to  certain  portions  of  tl»e  hold  by  fr<H^  ventilation,  not  a 
case  occurring  sav(^  within  certain  well-delined  limits,  within 
which  ventilation  was  impracticable. 

It  would  therefore  seem  that  3'ellow  fever  can  lie  ]iro- 
duced  only  when  the  atmos])here  has  become  loaded  with 
emanations  from  animal  and  vegetable  decom]>ositioii.  to 
which  must  be  added  the  speciilc  yellow-fever  ])oison  l^efore 
the  fever  can  be  ])ropagated  from  the  sick  to  the  healthy. 

While  the  advocates  of  the  doctrine  of  non  contagion  are 


92  YELLOW   FEVER. 

positive  as  to  tlie  non-contagious  character  of  yellow  fever, 
they  are  eqiiall}^  certain  that  it  is  a  portable  disease,  that 
is,  tliat  it  can  be  conveyed  from  one  locality  to  another  by 
means  of  clothing,  merchandise,  and  in  tlie  holds  of  vessels. 
They  also  believe,  when  yellow  fever  poison  is  thus  intro- 
duced into  healthy  localities  which  are  suited  by  tempera- 
ture and  the  presence  of  animal  and  vegetable  decomposition 
to  its  reproduction,  that  it  rapidly  and  repeatedly  repro- 
duces itself,  and  in  this  way  epidemics  of  yellow  fever  may 
be  developed  in  localities  which  are  usually  free  from  the 
disease.  Consequently,  it  is  a  disease  which  should  be 
guarded  against  in  any  seaport  by  a  vigorous  quarantine. 

How  long  yellow  fever  poison  may  retain  its  vitality  is 
not  3^et  positively  determined,  but  that  the  period  is  a  very 
long  one  tliere  can  be  no  question. 

One  may  visit  a  locality  where  yellow  fever  is  prevailing 
and  remain  in  it  for  a  considerable  time,  and  not  convey 
the  i^oison  in  the  clothing  beyond  the  boundaries  of  the 
district  where  the  disease  is  prevailing.  In  order  to  the  con- 
veyance of  the  poison  bej^ond  these  limits,  it  is  necessary 
that  the  clothing  become  so  saturated  with  the  poison  that 
it  will  not  become  neutralized  when  exposed  to  the  air  of  a 
non-infected  district. 

I  have  briefly  stated  to  you  all  of  the  important  well- 
ascertained  facts  that  bear  upon  this  vexed  question.  In 
conclusion,  it  may  be  stated  that  with  the  written  history 
of  the  disease  before  one,  there  is  not  sufficient  evidence  to 
lead  to  the  acceptance  either  of  the  doctrine  of  contagion,  or 
of  contingent  contagion.  It  seems  to  me  there  need  be  no  fear 
of  contracting  the  disease  by  visiting  those  sick  with  yellow 
fever  in  a  yellow  fever  district,  unless  such  visits  are  ver}^ 
much  prolonged.  The  poison  of  yellow  fever,  as  met  with 
in  the  holds  of  vessels,  sometimes  is  so  concentrated  that 
a  very  short  exposure  is  sufficient  to  overwhelm  the  nervous 
system,  and  give  rise  to  ver}^  urgent  nervous  phenomena, 
which  are  soon  followed  by  the  development  of  the  fever, 
and  from  such  exposure  it  is  possible  to  convey  the  poison 
in  the  clothing. 

The  length  of  the  period  of  intubation  varies  from  twelve 


SYMPTOMS.  93 

lioui'S  to  four  or  live  days;  it  is  claiiucd  by  some  lliaf  tliis 
])eri()d  of  iiiciihalioii  ma}'  «'Xtriid  over  a  jK'riod  of  srvcral 
wet'ks.  Wlicii  tlic  cxposiiic  is  foilou-cd  in  u  few  lioiiis  by 
the  lever,  llicycllow  fever  ])oisoii  must  necessarily  b(;  very 
coneeiitrated. 

Symptoms.- — Tiie  de\ cloiiuienl  of  yellow  fexci'  may  or  mav 
not  be  preceded  by  ])remonitoiy  sym])loms,  such  as  head- 
ache, pain  in-  the  limbs,  and  loss  of  ai)i)etile.  If  these  symj)- 
toms  are  ])resent,  they  are  l\v  no  means  characteiistic  of  the 
lever.  In  nearly  e\('ry  inslance  the  disease  is  nslien^d  in 
b}^  a  distinct  chill  ;  in  no  disease,  unless  it  may  ])e  i)uer- 
peral  fever,  is  a  chill  so  invarial)ly  an  nshei'ini^  in  symi)tom 
as  in  yellow  fever.  While  aj»i»arently  in  th(?  most  perfect 
health,  while  at  work,  or  even  while  aslee]),  jK^tients  will 
be  seized  with  a  slight  or  severe  chill,  and  immediately  be- 
come seriously  ill,  taking  their  beds  in  the  most  disheart- 
ened manner. 

You  will  remember  that  I  stated,  to  you  that  there  were 
both  mild  and  severe  types  of  typhoid  fever,  and  that  tliey 
differed  only  in  degree,  not  in  kind  ;  so  also  is  the  case  in 
yellow  fever,  and  you  must  remember  this  fact  when  con- 
sidering the  symptoms  of  this  fever. 

The  outline  of  the  clinical  histor}^  is  very  nearly  the  same 
in  a  mild  as  in  a  severe  type  of  the  fever.  Following  the 
(hill  or  rigor  which  usliers  in  the  attack,  tliere  is  supra- 
orbital headache,  pains  in  the  back  and  limbs,  which  are 
especially  severe  in  the  calves  of  the  legs.  The  counte- 
nance is  flushed,  the  conjunctiva  congested  ;  the  eye  has  a 
])(.'culiar  lustre  and  a  staling  look.  Tlie  temperature  rises 
rapidly,  and  reaches  102°  F.  within  a  few  liours  after  the 
chill.  The  temperature  in  yellow  fever  varies  very  much 
in  dilTcnvnt  cases.  In  sonu^  cases  it  never  rises  above  lOS" 
F.,  while  in  some  severe  e])idemics  it  has  ])een  recoi'ded  as 
high  as  110°  F.  Such  a  teni]»erature  is  veiy  seldom 
reached.  By  the  end  of  the  second  day  ihe  1iiii]m  laiure 
nsuall}'  reaches  its  maximum  heigln,  which  larely  is  higher 
tlijin  lo.")'  F.  In  this  countiy.  according  to  i-ecoids  made,  the 
temperature  lias  rarely  risen  highei- I  hail  jol  !•'.  Tlii<  fever 
is  not  characterized  by  >o  high  a  range  of  temperature  as  is 


94  YELLOW   FEVER. 

mot  Avitli  in  almost  all  the  otlier  varieties  of  fever.  From 
the  second  to  the  fourth  day  the  temperature  variations  are 
slight,  and  do  not  amount  to  distinct  remissions.  By  the 
fourth  day,  if  not  before,  the  temperature  falls  very  rap- 
idly, so  that  in  twelve  hours  the  normal  standard  may  be 
reached  ;  usually,  however,  it  does  not  fall  below  100°  F. 
This  fall  constitutes  a  distinct  remission.  This  period  of 
remission  may  last  from  a  few  hours  to  two  or  three  days, 
after  which  time  the  temperature  again  rises,  and  rapidly 
reaches  104°  F.,  or  even  rises  higher  ;  then  it  remains  sta- 
tionary from  twenty-four  to  forty-eight  hours,  after  which 
time  it  falls  to  the  normal  standard,  where  it  remains  until 
convalescence  is  established. 

In  accordance  with  the  temperature  variations,  the  dis- 
ease may  be  divided  into  three  stages :  a  first  stage,  or 
stage  of  invasion  ;  a  second  stage,  or  stage  of  remission  ; 
and  a  third  stage,  or  stage  of  exacerbation. 

Some  writers  have  divided  the  disease  into  a  febrile 
stage,  or  stage  of  exacerbation,  a  passive  stage,  or  stage  of 
remission,  and  a  stage  of  collapse. 


LECTURE    IX. 


YELLOW  FEVER. 


Sf/??iploms   {continued). — Differential    Diagnosis. — Proff- 
nos  is. — Treatm  ent. 


This  morning  I  would  invite  your  attention  to  the  farther 
study  of  tlie  symptoms  of  yellow  fever,  I  have  statt^d  to 
you  tliat  in  the  iiiMJority  of  instances  this  fever  is  usliered 
in  l)y  a  distinct  chill  ;  usually,  this  is  not  prolonged  ;  follow- 
ing rlit'  <'hill  there  is  a  rapid  rise  in  tem])crature,  wliich,  by 
the  third  or  fourth  day,  reaches  its  maximum  height,  from 
103^  F.  to  107"  F.  This  rise  in  temperatur<>  may  be  accom- 
panied by  dryness  of  the  surface,  or  the  surface  of  the  body 
may  be  bathed  in  a  profuse  ])erspirati()n.  Sometimes,  aft<'r 
the  chill  has  subsided,  there  is  an  unnatural  coldness  of 
the  surface,  and  there  seems  to  have  been  Jio  rise  in  tem- 
perature, but  the  thermometer  in  the  rectum  registers  104° 
F.  or  105°  F. 

PuLSK. — The  pulse  in  yellow  fever  is  never  accelerated  in 
proportion  to  the  rise  in  temperature.  It  rarely  becomes 
as  frequent  as  in  other  forms  of  continued  fever,  seldom 
reaching  more  than  110  beats  per  minute.  In  quite  severe 
cases  it  may  only  reach  loo,  and  in  the  milder  cases  it  may 
not  be  accelerated  more  than  live  or  six  beats.  It  has  a 
peculiar  character ;  many  writers  term  it  a  "g:\seous  ])uls(\" 
It  is  easih'  compressed  and  has  an  uncertain  volume  and 
cliaracter.  This  peculiarity  of  pulse  is  an  element  of  diller- 
ential  diagnosis. 


00  YELLOW   FEVER. 

Eye. — The  eye  is  suffused,  and  the  conjunctiva  becomes 
congested  quite  early  in  the  disease.  The  appearance  of  the 
countenance  in  severe  cases  has  almost  uniformly  been 
regarded  as  diagnostic  of  this  disease.  The  eyes  are  red 
and  watery,  and  the  conjunctivae  are  so  intensely  congested 
that  the  eyes  resemble  two  balls  of  fire,  while  the  face  has  a 
dusky,  deathly  hue  ;  these  give  to  the  countenance  a  re- 
markable expression  of  dejection  and  distress. 

Tongue. — The  tongue  is  early  covered  with  a  thick  white 
coating,  except  at  its  tip  and  edges,  which  are  red,  and  in 
fatal  cases,  towards  the  close  of  life,  sometimes  the  tongue 
becomes  dry,  brown,  cracked,  and  fissured,  resembling  the 
tongue  of  typhoid  fever.  There  is  loss  of  appetite,  and 
from  the  very  onset  of  the  disease  there  is  more  or  less 
nausea  and  vomiting. 

YoMiTiNG. — Nausea  and  vomiting  may  be  regarded  as 
among  the  most  constant  and  characteristic  symptoms  of 
3^ellow  fever.  They  come  on  soon  after  the  chill,  and  con- 
tinue throughout  the  entire  course  of  the  fever.  At  first  the 
matters  vomited  are  simply  the  contents  of  the  stomach, 
then  they  become  yellowish  or  greenish  in  color,  are  fluid, 
and  have  an  alkaline  reaction.  There  is  nothing  about  the 
matters  vomited  that  is  characteristic  of  yellow  fever.  If 
the  vomiting  subsides  without  any  other  changes  in  their 
character,  it  is  quite  evident  that  the  case  is  going  on  to 
recovery.  In  the  fatal  cases  the  vomiting  continues  un- 
til a  few  hours  previous  to  death,  and  in  some  cases  until 
the  hour  of  death.  In  a  large  proportion  of  these  cases 
there  is  finally  developed  the  striking  and  well-known 
hIacTc  vomit,  wliich  has  been  regarded  as  characteristic  of 
this  fever,  and  which  by  some  is  supposed  to  occur  only  in 
this  disease.  This  peculiar  vomiting  ma}^  occur  upon  the 
second  or  third  day  of  the  fever,  but  more  commonly  it 
does  not  come  on  until  thirty-six  or  forty-eight  hours  pre- 
vious to  death,  or  not  until  the  day  of  death.  It  undoubt- 
edly occurs  more  frequently  in  yellow  fever  than  in  any 
otlier  disease,  but  it  difl'ers  in  none  of  its  constituents 
from  a  similar  material  which  is  sometimes  vomited  in  other 
diseases.     A  microscopical  examination  of  the  black  vomit 


SYMPTOMS.  1)7 

sItows  it  to  ronsist  of  ])i<;iiii'iit.  iiKittii-  in  tin-  rorm  of  llip- 
graiuilt's,  a<j:,u'n'ii::itc(l  iioii-uraMular  masses,  and  globules 
which  resonible  l)Iood-gh)l)iiles.  In  addition  to  tlii.s  color- 
ing matter  there  are  found  epitlielial  cells  from  the  mucous 
meml)raii(M)f  th»'  stomach,  lym])hoi(l  ci-lls  or  wliitc  irlohiiles 
which  liave  undericone  degeneration,  and  sei-ous  Ihiid.  The 
pigment  material  is  due  to  changes  produced  b}'-  the  action 
of  the  gastric  secretions  upon  the  blood  that  has  esca])ed 
from  the  walls  of  the  vessels  of  the  mucous  membrane  of 
the  stomach  into  its  cavity.  The  action  of  this  gastric  secre- 
tion upon  the  red  blood-globules  is  such  as  to  permit  the 
escajie  of  their  coloring  uiatter  in  the  form  of  granules  or 
small  rounded  masses.  The  same  change  will  occur  when- 
ever lilood  escapes  in  small  quantities  by  a  ca])illary  hemor- 
rhage into  the  cavity  of  the  stomach.  Although  this  may 
occur  in  other  diseases,  yet  when  it  does  occur  in  yellow 
fev(M\  it  should  be  regarded  as  a  grave  s3nu])tom.  The 
vomiting  is  projectile  in  character,  and  in  this  respect  is 
peculiar  to  this  fever. 

The  bowels  are  usually  constipated.  If  diarrhoeal  dis- 
charges are  present,  generally  they  are  of  a  dark  color, 
and  frequently  contain  fluid  blood,  as  there  is  the  same  ten- 
dency to  capillary  hemorrhage  from  the  mucous  membrane 
of  the  intestines  as  from  the  stomach. 

Urine. — The  changes  in  the  urine  are  regarded  by  some 
as  diagnostic.  Early  in  the  disease  it  has  an  acid  reaction. 
As  soon  as  bile  is  jiresent  in  the  urine  its  reaction  becomes 
alkalint\  By  some  this  alkalinity  is  regarded  as  an  evidence 
of  commencing  convalescence,  but  there  is  no  reason  for 
such  an  opinion,  for  this  cliange  in  the  urine  might  be 
expected  as  soon  as  bile  becomes  one  of  its  constituent 
parts,  but  it  is  not  due  to  any  ])eculiar  action  of  the  yellow 
fever  poison. 

Albumon  has  been  found  in  the  urine  in  all  fatal  cases, 
and  early  in  the  attack,  it  has  been  found  present  in  moder- 
ate quantity,  in  all  severe  cases,  but  as  the  disease  progressed 
it  became  more  or  less  abundant  according  to  the  severity 
of  the  fever.  Entire  auppresmion  of  urine  is  of  frequ^•nt 
occurrt^nce  in  severe  cases,  and  no  symptom,  not  even  the 
7 


98  YELLOW   FEVER. 

black  vomit,  is  so  unfavorable  as  tlie  complete  suppression  of 
urine.  A  patient  with  black  vomit  does  not  necessarily 
die,  but  complete  suppression  of  urine  is  almost  invariably 
followed  b}^  a  fatal  termination. 

Under  the  head  of  the  morbid  anatomy  of  this  disease 
were  described  the  kidney  lesions  which  account  for  the 
suppression  of  urine  ;  for  if  the  kidney  changes  are  exten- 
sive, it  is  impossible  for  these  organs  to  perform  their  func- 
tion, and  death  is  the  necessary  result,  for  acute  ursemia  is 
added  to  the  fever  poisoning. 

Delirium  is  rarely  present,  but  when  it  occurs  it  is  wild 
in  character,  and  it  is  marked  by  a  constant  desire  on  the 
part  of  the  patient  to  get  away  from  some  impending  dan- 
ger. Usually  the  mind  is  clear,  but  a  peculiar  apathy  takes 
possession  of  these  patients,  and  they  often  lie  in  a  state  of 
complete  collapse,  with  shrunken  features,  entirely  indiffer- 
ent and  unconcerned  as  to  their  condition. 

Jaujstdice. — The  yellow  color  of  the  skin,  which  is  so 
prominent  and  constant  a  symptom  of  yellow  fever,  usually 
does  not  appear  until  about  the  third  day  of  the  fever.  It 
is  first  noticed  about  the  eyes,  but  soon  extends  over  the 
entire  body.  Some  have  maintained  that  this  discoloration 
of  the  skin  is  a  true  jaundice,  due  to  a  retention  and  reab- 
sorption  of  bile,  in  the  same  manner  as  we  liave  acute  jaun- 
dice following  an  obstruction  of  the  gall  duct.  Those  who 
do  not  accept  this  doctrine  maintain  that  the  gall  ducts  are 
not  found  obstructed,  hence  there  is  no  reason  for  the  reten- 
tion and  reabsorption  of  the  bile. 

The  true  etiology  of  the  jaundice  in  yellow  fever  may  be 
stated  as  follows  :  the  yellow  fever  poison  is  introduced 
into  the  circulation,  and  produces  its  specific  changes  in  the 
blood  ;  that  is,  the  red  globules  are  destroyed  within  the 
circulation,  the  li;ematine  in  them  is  changed  into  pigment 
matter,  and  a  staining  of  the  tissues  of  the  body  follows, 
which  is  a  real  hsematogenous  jaundice. 

Admitting  these  blood-changes  to  have  taken  place,  we 
find  a  ready  explanation  of  many  other  changes  which  take 
place  in  this  disease.  The  blood-globules  to  a  great  extent 
are  destroyed,  and  in  consequence  the  blood  loses  its  vital- 


SYMPTOMS.  90 

izing  power.  Tliis  induces  defoctivo  nutrition.  ;nid  l^ads  to 
futty  dcm'ui'ration  of  tlu'  liver  cclLs  and  tin?  renal  epithe- 
lium. Tile  walls  of  the  eai)illary  vessels  become  enfeel)led, 
to  which  is  added  the  qualitative  alterations  in  tli*-  MixmI 
itself,  and  these  lead  to  hennji-rha^ic  extravasations  in  vari- 
ous parts  of  the  body  which  nuirk  the  progress  of  this  dis- 
ease. 

It  is  of  importance  that  you  remember  that  in  yellow 
fever,  about  the  third  or  fourth  day,  sometimes  within 
twenty-four  hours  from  the  commencement  of  the  attack, 
the  tem]>erature  rapidly  falls,  so  that  in  twelve  hours  it 
may  reach  its  normal  standard.  In  the  majority  of  in- 
stances it  does  not  fall  below  100°  F.,  and  there  is  no  dis- 
tinct intermission,  but  a  decided  remission.  The  pain  in 
the  head  and  back  now  subsides,  the  patient  is  in  every 
way  very  much  improved,  and  you  may  consider  him  con- 
valescing. Yet,  in  a  day  or  two,  there  may"  be  a  return  of 
all  the  febrile  and  other  distressing  symptoms  which  were 
present  in  the  early  period  of  the  fever ;  after  these  have 
continued  for  twenty-four  or  forty-eight  hours,  usually 
convalescence  is  established  ;  especially  is  this  the  case 
when  recovery  is  to  take  place  as  soon  as  the  remission  is 
established.  In  such  cases,  with  the  remission,  the  pain  in 
the  epigastrium,  the  vomiting,  and  the  yellow  discoloration 
of  the  skin  all  begin  to  subside.  The  patient  is  now  able  to 
take  nourishment,  and  with  the  occurrence  of  these  symp- 
toms, if  the  surface  has  btM»n  dry,  a  slight  moisture  ap})ears, 
and  the  patient  soon  passes  into  a  state  of  convalescence. 

On  the  other  hand,  the  vomiting  maj'  continue,  and  the 
black  vomit  appear;  the  distress  and  burning  in  the  epigas- 
trium may  become  more  and  more  severe  ;  there  is  greater 
restlessness,  tossing,  and  agitation;  the  albumen  in  the 
urine  is  more  abundant  ;  the  urine  becomes  more  and  more 
scanty,  until  tinall}^  complete  su])pression  occurs,  and  coma 
and  death  follow. 

Some  epidemics  are  marked  l»y  a  ]»redoniinaiice  of  one 
class  of  symptoms  and  some  hy  the  predominance  of  an- 
other class,  so  that  it  is  difficult  to  give  a  history  of  this 
fever  which  shall  accord  with  all  its  different  modes  of  de- 


100  YELLOW   FEVER. 

velopment.  Consequently,  there  have  been  many  varieties 
of  yellow  fever  described,  such  as  the  comatose,  the  algid, 
etc.  Strictly  speaking,  these  so-called  varieties  are  simply 
variations  in  the  clinical  manifestation  of  the  disease  pro- 
duced by  the  degree  of  poisoning,  and  by  some  peculiarity 
in  the  atmospheric  conditions  under  which  it  prevails. 

Some  epidemics  are  much  more  fatal  than  others,  and  the 
ratio  of  mortality  is  much  less  during  the  latter  part  than 
during  the  early  part  of  an  epidemic. 

At  the  present  time,  there  seems  to  be  little  question  but 
that  the  immediate  cause  of  death  in  all  severe  epidemics 
of  yellow  fever  is  due  to  uremia.  The  yellow  fever  first 
produces  its  changes  in  the  blood,  which  leads  to  such 
glandular  changes,  especially  of  the  kidneys,  as  arrest 
glandular  functions,  and  a  secondary  blood-poisoning  is 
the  result. 

Some  writers  have  described  a  j)eriod  of  collapse.  It  is 
true  that  a  condition  of  collapse  not  unfrequently  occurs, 
but  it  is  nothing  more  than  a  period  of  commencing  death. 

Differential  Diagnosis. — Yellow  fever  has  been  con- 
founded with  malarial  fever,  relapsing  fever,  and  with  acute 
atrophy  of  the  liver.  Under  ordinar}'  circumstances  the 
diagnosis  of  yellow  fever  is  not  difficult,  yet  there  are  cer- 
tain types  of  malarial  fever  which  are  especially  liable  to 
be  mistaken  for  it. 

Some  writers  have  even  gone  so  far  as  to  maintain  that 
the  so-called  bilious-remittent  is  only  a  modification  of  yel- 
low fever.  At  the  present  day,  it  has  been  fully  established 
that  each  is  a  distinct  type  of  fever.  The  following  are  the 
points  of  differential  diagnosis  between  them : 

First. — The  character  of  the  prevailing  disease,  the  re- 
gion in  which  it  prevails,  and  the  manner  of  its  endemic  or 
epidemic  development.  Yellow  fever  prevails  in  seaports, 
remittent  fever  in  inland  towns.  Yellow  fever  is,  remit- 
tent fever  is  not  portable. 

Second. — The  difference  in  the  manner  of  invasion  of  the 
two  diseases,  the  difference  in  the  range  of  temperature,  the 
projectile  character  of  the  vomiting  in  yellow  fever,  and  its 
non-projectile  character  in  remittent,  the  peculiar  character 


DIl'FKKKN  riAL    DTACN'OSIS.  KM 

of  l)iilst' in  yellow  t'i'vcr,  as  well  as  ilic  almost  characteris- 
tic oxi)n'Ssi(Hi  of  tlic  coiiutciiaMcc,  is  quite  sullicieiit  to  dis- 
tiii<j;iiisli  it  even  from  the  so-called  yellow  ty]>('  of  remittent 
fever.  Then  the  difference  in  the  aiiatoinical  ch:inires,  and 
in  tlie  elVect  of  quinine  in  the  two  diseases  is  veiy  st^ikini,^ 
There  is  a  yellow  discoloration  of  the  skin  in  l>oth  diseases. 
but  it  appears  earlier  and  is  more  intense  in  yellow  than  in 
remittent  ftn-er.  The  presence  of  an  enhnp'd  si)leen  would 
lead  to  the  diaf^nosis  of  remittent  rather  than  yellow  fever. 

Helapshig  Femr. — At  the  first  appearance  of  this  dis- 
ease in  a  new  locality  it  may  l)e  confounded  witli  yellow 
fever.  You  will  be  led  to  a  correct  diagnosis  by  study- 
ing the  etiological  relations  of  the  two  diseases.  Relaps- 
ing ferer  i.9,  yellow  fever  is  not,  propagated  by  contagion. 
Then,  the  almost  tyjiical  range  of  temperature  in  relapsing 
fever  furnishes  a  marked  distinction  between  it  and  yellow 
fever.  In  the  former  if  yellow  discoloration  of  the  skin  is 
developed,  it  does  not  come  on  until  late,  generally  not 
until  the  relapse.  An  enlarged  spleen  is  the  rule  in  relaps- 
ing, and  the  exception  in  yellow  fever.  Hemorrhage  from 
the  mucous  surfaces  may  occur  iu  both  these  types  of  fever, 
and  there  can  be  little  question  but  that  the  blood-changes 
are  very  similar  in  kind,  but  not  in  degree,  in  these  two 
forms  of  fever.  During  the  past  two  years,  in  the  wards  of 
Bellevue  Hospital,  in  two  instances,  has  acute  yellow  atro- 
pliy  of  the  liver  been  mistaken  for  yellow  fever.  If  an 
accurate  history  of  the  cases  could  have  been  obtained, 
doubtless  the  mistake  in  diagnosis  would  not  have  been 
made. 

In  yellow  atrophy  of  the  liver,  as  well  as  in  yellow  fever, 
there  is  jaundice  with  fever,  and  vomiting  of  a  black  mate- 
rial accompanied  by  suppression  of  urine  ;  but  the  liistory 
of  the  devel()]iment  of  the  two  diseases  and  the  gradual  but 
steady  diminution  in  the  siz«>  of  the  liver  in  yellow  atro])hy, 
while  in  yellow  fever  the  organ  rather  increases  than  dimin- 
ishes in  si/e.  is  sufficient  for  a  diagnosis. 

The  difficulties  which  attend  the  dilFerential  diagnosis  of 
yellow  fever  aie  often  very  great ;  in  fact,  sometimes  it  is 
impossible  to  make  a  i)Ositive  diagnosis.     For  example,  some 


102  YELLOW   FEVER. 

of  the  crew  of  a  ship  coming  from  an  infected  port  become 
jaundiced,  have  hemorrhage  from  the  mucous  surfaces,  ac- 
companied by  fever  of  a  remittent  type  ;  if  these  patients 
have  previously  suffered  from  intermittent  fever,  attended 
by  an  enhirgement  of  the  spleen,  it  will  be  almost  impossible 
in  the  earlier  cases  to  decide  between  so-called  bilions-re- 
mittent  and  yellow  fever. 

Prognosis. — The  average  duration  of  yellow  fever  is  six 
daj^s  ;  sometimes  it  destroys  life  in  three  days.  The  prog- 
nosis greatly  varies  in  different  epidemics.  The  highest 
recorded  ratio  of  mortality  which  I  have  been  able  to  find 
is  one  death  in  every  three  cases. 

Some  writers  have  claimed  that  more  than  one-half  the 
cases  are  fatal,  but  upon  a  careful  examination  of  statistics 
I  find  they  give  no  such  percentage  of  death.  In  some 
epidemics  the  fever  is  of  so  mild  a  type  that  only  a  very 
few  cases  terminate  fatally,  perhaps  one  in  fifteen  or  twenty. 

A  consideration  of  the  following  conditions  is  of  impor- 
tance in  making  our  prognosis  : 

The  severity  of  the  invasion  of  the  fever.  The  intensity 
of  the  febrile  excitement.  The  early  appearance  of  the 
yellow  tinge  of  the  skin  and  the  intensity  of  the  jaundice. 
The  greater  the  severity  of  the  period  of  invasion,  the 
higher  the  range  of  temperature  ;  the  deeper  the  jaundice, 
and  the  greater  the  amount  of  albumen  in  the  urine,  the 
more  unfavorable  is  the  prognosis.  If  the  quantity  of  albu- 
men diminishes,  the  patient  is  advancing  toward  recovery  ; 
if  it  increases,  a  fatal  termination  is  indicated. 

The  elements  of  a  favorable  and  unfavorable  prognosis 
may  be  briefly  stated. 

The  fai^orahle  symptoms  are  a  slow  pulse,  a  slight  rise  in 
temperature,  a  quiet  stomach.  Streaks  of  blood  during  the 
latter  stage  of  the  fever  are  not  regarded  as  indicating 
danger,  especially  if  the  blood-corpnscles  are  entire.  Al- 
buminous urine  without  casts  is  not  of  serious  import. 
Under  all  circumstances,  a  copious  secretion  of  urine  must 
be  regarded  as  a  favorable  symptom. 

A  recent  residence  in  a  temperate  climate  will  enter  very 
largely  into  the  chances  of  recovery  from  3^ellow  fever. 


PROGNOSIS.  103 

Tlu^  tcnfawrahle  synrptoms  are:  a  higli  temporal uiv,  a 
red  toiiixiK'.  nil  irritable  stoiiiacli,  intense  i)ain  in  tin?  liead, 
scanty  urine,  containinu-  albninen  and  casts,  black  vomit,  a 
faltering  articulation,  and  dilliculty  in  jirotruding  tlu.^ 
tongue.  A  streak  of  blood  in  the  early  vomit  indi<'ates 
great  danger,  especially  if  the  blood-globules  are  l)roken 
down.  The  intensity  of  tin-  jaundice,  and  ihefact  that  the 
])atieiit  has  rec«Mitly  suiTered  i'roiuan  attack  of  yellow  IVver, 
render  the  ])rognosis  unfavorable. 

In  a  large  number  of  cases  you  will  lind  great  difficulty 
in  giving  a  positive  prognosis.  The  presence  of  the  "black 
vomit"  and  an  entire  suppression  of  urine  render  a  case 
almost  liopeless,  as  lias  already  been  stated.  Recovery 
after  the  occurrence  of  "black  vomit"  is  more  frequent 
than  after  suppression  of  urine.  In  mild  and  in  severe 
cases  the  period  of  convalescence  is  in  proportion  to  the 
duration  of  tlie  disease.  In  some  cases  it  is  not  fully 
established  until  two  weeks  after  the  cessation  of  the  febrile 
symptoms.  Complete  recovery  does  not  take  place  in  some 
cases  until  five  or  six  months  after  the  commencement  of 
convalescence. 

There  are  no  certain  sequelae  of  yellow  fever.  Cellulitis 
and  abscesses  are  spoken  of  by  some  writers,  but  they  are 
by  no  means  constant. 

Tkeat3[ENT. — Before  considering  in  detail  the  treatment 
of  yellow  fever,  I  would  say  a  few  words  concerning  its 
prophylaxis.  The  ])rophy]actic  measures  for  tlie  most  part 
are  included  under  the  general  head  of  quarantine  regula- 
tions. It  is  possible  by  strict  quarantine  to  prevent  the 
introduction  of  j'ellow  fever  into  any  district  or  seaport 
where  it  is  not  indigenous.  It  is  not  necessary  that  I  should 
enter  upon  a  discussion  of  those  quarantine  regulations 
wliich  have  been  found  most  successful  in  ])reventing  the 
introduction  of  this  disease;  tlu'se  come  rather  within  the 
province  of  State  medicine.  If  you  lind  yourself  in  a  re- 
gion visited  by  an  epidemic  of  yellow  fever,  you  may  escape 
it  by  removing  ])ey()nd  the  limits  of  the  iid'fi-ted  district.  If 
you  are  compelled  to  remain  within  tin-  limiis  wlnrc  tlif 
epidemic  is  prevailing,  avoid  ever\"thing  which  is  regarded 


104  YELLOW  FEVER. 

as  a  predisposing  cause  of  the  disease.  Under  sueli  circum- 
stances most  observers  regard  tlie  sulpliate  of  quinine,  taken 
daily  in  moderate  doses,  as  a  proplij-lactic  agent. 

The  details  of  the  treatment  to  be  employed  when  the 
disease  has  once  established  itself  are  very  unsatisfactory  ; 
perhaps  there  is  no  disease  the  treatment  of  which  is  more 
unsatisfactory.  Medical  men  widely  differ  as  to  the  most 
effectual  means  to  be  employed  in  controlling  or  mitigating 
the  severity  of  the  fever.  Physicians  in  India,  and  Ameri- 
can physicians  who  have  come  in  contact  with  this  fever, 
treat  it  very  differently.  Within  the  past  few  years  there 
has  been  a  marked  change  in  the  views  of  American  physi- 
cians in  regard  to  its  treatment. 

The  remedial  agents  which  have  been  most  extensively 
used  are  mercurials,  bleeding,  stimulants,  and  quinine.  It 
is  very  difficult  to  accurately  estimate  the  relative  value  of 
these  different  agents,  for  this  reason,  there  are  certain 
forms  of  this  fever  in  which  no  treatment  avails  anything, 
the  patient  receives  his  death-blow  at  the  very  onset  of  the 
fever.  On  the  other  hand,  there  are  forms  of  so  mild  a  type 
that  the  patient  is  almost  certain  to  recover.  Hence  the 
great  uncertainty  which  attends  any  plan  of  treatment,  and 
the  nnreliableness  of  statistics  in  regard  to  its  effects. 
Under  all  plans  of  treatment  there  are  many  deaths  and 
many  recoveries.  I  have  already  alluded  to  the  four  leading 
plans  of  treatment  which  have  been  resorted  to  for  the 
management  of  this  fever,  namely,  the  mercurial,  the  blood- 
letting, the  stimulant,  and  quinine  plan.  The  plan  now 
most  generally  adopted  is  the  expectant,  or,  as  it  is  called 
by  some,  the  diaphoretic. 

At  one  time  blood-letting  was  very  extensively  practised 
in  the  treatment  of  yellow  fever,  one  hundred  and  eighty 
ounces  of  blood  have  been  drawn  from  the  temporal  artery 
at  a  single  bleeding.  The  most  experienced  and  intelligent 
physicians,  with  the  largest  opportunities  for  observation, 
have  abandoned  this  plan  of  treatment,  which  fact  is  suf- 
ficient argument  against  it.  The  same  is  true  of  the  mer- 
curial plan  of  treatment ;  now  mercury  is  onl}'  employed  as 
a  cathartic  at  the  very  commencement  of  the  fever. 


/ 


TUKAT.MKNT.  105 

Till'  stiiuulatiiiu;  plan  of  treatment  has  also  iallen  into  dis- 
ivi>ntt'.  It  was  found  that  the  ailniinistration  of  sliunilants 
during  the  active  period  of  the  fever  was  not  followed  by 
good  results. 

xVgain,  our  nn)st  competent  observers  unhesitatingly  de- 
clare that  quinine  has  no  controlling  power  over  the  fever. 

Let  us  i)ause  a  moment  and  consider  what  are  the  indica- 
tions as  to  treatment. 

The  great  danger  in  yellow  fever  is  that  tin-  kidm  ys  will 
fail  to  ])erform  their  function. 

What  more  sensible  plan  of  treatment  than  that  which 
contem])lates  relieving  the  kidneys  from  excessive  work  ? 
Here  is  an  opportunity  for  the  use  of  diaphoretics,  and  a 
certain  amount  of  cathartic  medicine,  not  to  use  them  to 
such  an  extent  as  to  produce  exhaustion,  but  so  far  as  to 
afford  as  much  relief  as  possible  to  the  kidneys. 

At  the  commencement  of  the  attack  counter-irritation 
over  the  region  of  the  kidneys  is  undoubtedly  of  great 
service. 

The  plan  of  treatment  now  most  generally  recommended 
and  adopted  is,  as  soon  as  a  patient  is  taken  with  yellow 
fever,  in  addition  to  the  application  of  counter-irritants  over 
the  region  of  the  kidneys,  to  administer  ten  grains  of  calomel 
combined  with  ten  grains  of  quinine.  Why  the  quinine  is 
added  to  the  calomel  I  do  not  know.  Keep  up  a  moderate 
dia])lioresis.  At  the  same  time  administer  lime-water  and 
milk,  which  is  said  to  have  greater  control  over  the  nausea 
and  vomiting  than  any  other  means  which  have  been  em- 
plo3'ed. 

It  has  been  recommended  that  the  surface  should  be 
bathed  with  some  alkaline  lotion,  on  the  theory  that  alka- 
lines  applied  to  the  surface  have  a  controlling  influence 
over  the  vomiting.  There  are  no  reliable  facts  to  sustain 
this  theory. 

In  severe  cases,  during  the  fever,  there  is  usually  nausea, 
great  restlessness,  with  tossing  and  rolling  of  the  head.  In 
order  to  quiet  this  uneasiness  and  jactitation  some  liave  pro- 
posed tlie  use  of  chlorodine,  otliers  the  administration  of 
chloroform,  but  all  have  i)rotested  against  the  use  of  opium, 


106  YELLOW   FEVER. 

because  of  tlie  kidney  lesions,  insisting  that  by  the  use  of 
opium  in  any  form  we  ran  the  risk  of  causing  additional 
disturbance  of  the  function  of  the  kidneys. 

I  regard  this  restlessness  to  a  great  extent  as  due  to  the 
effect  produced  upon  the  nerve  centres  by  the  urea  in  the 
circulation,  and  believe  that  all  these  nervous  manifesta- 
tions can  best  be  controlled  by  the  hypodermic  use  of  the 
sulphate  of  morphine. 

Perhaps  it  may  be  worthy  of  mention  that  a  physician 
living  in  the  West  Indies  has  recently  quite  successfully 
treated  cases  of  yellow  fever  by  administration  of  carbolic 
acid  in  doses  of  one  and  a  half  to  two  grains  every  two 
hours.  It  is  claimed  that  the  carbolic  acid  given  in  this 
way  arrests  the  changes  in  the  blood  produced  by  the  yel- 
low fever  poison.  I  should  question  very  much  if  carbolic 
acid  has  any  such  power. 

As  the  course  of  this  fever  is  very  rapid,  it  is  of  the  utmost 
importance  to  sustain  the  vital  powers  as  far  as  possible  till 
the  morbid  processes  come  to  an  end.  This  is  always  diffi- 
cult on  account  of  the  great  irritability  of  the  stomach— but 
as  soon  as  the  stomach  is  in  a  condition  to  receive  food,  you 
must  endeavor  to  improve  the  composition  of  the  blood  by 
a  most  nutritious  diet,  combined  with  wine,  quinine,  and 
iron. 


MALARIAL    FEVERS. 


LECTURE    X. 


MALAIHAL    FEVERS. 
Introduction. 

When  I  began  the  liistoiy  of  fevers,  you  will  remember 
that  I  divided  tliem  into  three  general  classes,  namely,  the 
contagious,  the  malarial,  and  the  miasmatic-contagious. 

This  morning  I  commence  the  history  of  those  which  are 
included  under  the  head  of  malarial  fevers.  I  pursue  this 
course  for  the  reason  that  I  believe  you  will  be  better  pre- 
pared to  study  contagious  fevers  after  you  shall  have 
become  familiar  with  the  malarial.  The  different  varieties 
of  malarial  fever  are  like  difl'erent  branches  of  the  same 
tree;  they  have  many  things  in  common,  yet  dilftn-  from 
each  other  so  widely  in  the  phenomena  which  attend  tlirir 
development,  that  they  may  be  regarded  as  distinct  dis- 
eases. They  have  a  common  origin  in  a  poison  which  has 
received  the  name  of  miasm. 

All  varieties  of  these  fevers  depend  upon  one  and  the 
same  poison,  which  is  subject  to  certain  variations  in  quan- 
tity. The  concentration  of  this  poison  determines  the 
severity  and,  to  a  certain  extent,  the  type  of  the  fever.  It 
is  possible  to  arrange  the  different  types  in  a  progressive 
scale,  from  the  mildest  to  the  most  severe,  beginning  with 
the  simple  intermittent  and  passing  on  to  the  most  severe 
type  of  pernicious  fever.  Tiie  extent  of  the  morbid  pro- 
cesses, and  the  ra])idity  with  which  they  are  developed, 
depend  upon  tlie  intensity  of  the  malaiial  ])()is()ii.  tlie 
length  of  time  the  individual  has  been  uikI-t  its  iiiUiience, 


110  MALARIAL  FEVERS. 

and,  to  some  extent,  "apon  individual  idiosyncrasies.  Many 
tlieoiies  liave  been  advanced  as  to  the  nature  of  this  miasm 
or  malarial  poison.  By  some  it  is  regarded  as  gaseous  in 
its  nature  ;  others  believe  it  to  be  a  living  vegetable  organ- 
ism ;  and,  again,  others  think  it  is  a  specific  poison,  having 
no  tangible,  chemical,  or  microscopical  constituents. 

No  one  of  these  theories,  nor  of  the  many  others  which 
at  different  times  have  been  advanced,  have  been  sustained 
either  by  facts  or  by  reliable  chemical  or  microscopical 
analysis.  Thus  far  we  have  no  positive  knowledge  in  regard 
to  its  true  nature,  but  we  do  know  something  of  the  cir- 
cumstances which  are  necessary  for  its  production  and  the 
laws  which  regulate  its  development. 

J^irst. — There  must  be  a  certain  amount  of  vegetable 
matter,  either  on  the  surface  or  in  the  substance  of  the  soil, 
where  the  malarial  poison  is  generated.  It  is  not  necessary 
that  the  quantity  be  large,  but  a  certain  amount  is  a  neces- 
sity. 

Second. — A  certain  amount  of  moisture  must  be  on  the 
surface  or  in  the  substance  of  the  soil ;  it  need  not  be 
excessive  ;  but  some  is  indispensable. 

Third. — A  certain  average  degree  of  temperature  is  neces- 
sary for  its  production.  It  cannot  be  developed  below  an 
average  temperature  of  58°  F.  for  the  twenty -four  hours, 
and  will  not  prevail  as  an  epidemic  unless  the  average  tem- 
perature ranges  as  high  as  65°  F.  for  the  twenty-four  hours. 

In  regions  where  these  fevers  prevail,  their  type,  form, 
and  intensity,  to  a  great  degree,  depend  upon  the  height 
of  the  temperature. 

As  a  rule,  malarial  fevers  are  endemic,  rarely  extending 
over  large  sections  of  country  in  the  form  of  an  epidemic. 
I  will  repeat,  three  things  are  known  to  be  necessary  to  the 
development  of  miasm  or  malarial  poison,  namely  :  t7ie 
presence  of  decomposing  organic  matter.,  a  certain  amount 
of  moisture.,  and  a  certain  arierage  range  of  temperature. 

We  also  have  some  knowledge  concerning  the  regions  in 
which  malarial  fevers  are  most  likel}^  to  prevail,  and  which 
seem  most  favorable  to  the  development  of  malarial  poison. 

First. — Marshes  are  especially  favorable  to  the  develop 


T\Ti:oi>rrTrox.  Ill 

ment  of  tliis  ])oison,  mikI  mwy  i^onorate  it  for  nn  indfli- 
nito  period.  The  Ponliin^  iiiiirslies  litivc  Ixmmi  iruiliuial  for 
more  tlmii  two  tliousaiul  years.  Yet  all  marshes  are  not 
malarial ;  their  power  to  ireiierate  the  malarial  poison  varies 
with  the  amount  of  water  the}'  contain.  Where  there  is  an 
abnndaiu-e  of  water,  malarial  fevers  are  rare;  when  they 
are  covered  only  l>y  a  thin  sheet  of  water,  and  are  exposed 
to  the  direct  rays  of  the  sun,  malarial  poison  will  abound. 
Marshes  that  have  dried  nj)  are  especially  favoi-iMe  to 
tile  develojmient  of  this  poison,  yet  as  soon  as  heavy  rains 
sul)merge  the  previously  j^arched  surface,  the  power  to 
generate  the  poison  is  for  a  time  diminished  or  entirely 
arrested. 

Scattered  here  and  there  over  our  own  continent  are 
districts  which  have  been  malarial  ever  since  the  white  man 
has  held  possession  of  them  ;  whether  such  was  the  case  in 
earlier  times,  our  history  is  too  uncertain  for  ns  to  de- 
termine. 

As  a  rule,  salt-water  marshes  are  especially  free  from 
malaria,  but  when  salt  and  fresh  water  become  mixed  in 
the  marsh,  as,  for  instance,  on  the  New  Jersey  Hats,  you 
liave  the  most  favorable  conditions  of  marsh  for  its  abun- 
dant dtn-elopment.  Those  marshes  resting  on  a  sul)stratum 
of  sand  are  far  less  malarial  than  those  resting  on  lime- 
stone, clay,  or  mud. 

There  are  marshes  in  the  higher  latitude  of  our  own  and 
other  States  which  often,  during  the  heat  of  summer,  be- 
come dry,  yet  no  malarial  poison  is  generated  (although 
during  the  day  the  thermometer  may  reach  00°  F. ) ;  for 
this  reason,  that  during  the  night  the  atmosjtheric  temper- 
ature falls  below  50°  F. 

There  are  some  quite  extensive  marslies  in  which  a])par- 
ently  every  condition  for  the  development  of  malaria  exists, 
and  yet  none  is  generated.  We  cannot  account  for  this 
fact,  unless  we  accept  tlie  theory  that  the  ozone  which  is 
claimed  to  be  present  in  such  marshes  arrests  or  pi-events 
its  generation. 

"Damp  bottom-lands"  that  are  exposed  to  an  annual 
overflow,  such  as  are  found  along   the  scuithern  shon'S  of 


112  MALARIAL   FEVERS. 

the  Mississippi  River,  are  as  fruitful  as  swampy  regions  in 
tlie  generation  of  this  poison. 

Second. — Another  condition  which  seems  to  favor  the 
development  of  malaria  is  the  upheaval  of  new  alluvial 
soils,  such  as  obtain  when  new  lands  are  first  brought 
under  cultivation.  This  same  state  of  things  also  occurs 
throughout  the  middle  and  southern  portions  of  this  State, 
and  in  the  ISTew  England  States. 

Where  railroad  excavations  are  made,  malarial  fever  is 
very  frequently  developed. 

In  this  city,  while  the  so-called  "  Fourth  avenue  im- 
provements" were  being  made,  the  entire  region  along 
the  avenue  was  rendered  highly  malarious  by  the  excava- 
tions. Such  excavations  bring  decomposing  vegetable 
matters  to  the  surface  ;  these,  under  the  intiuence  of  heat 
and  moisture,  generate  miasm. 

The  fact  that  fevers  of  this  type  appear  in  regions  pre- 
viously free  from  them,  as  soon  as  these  conditions  favor- 
able to  their  development  exist,  is  confirmed  by  the  testi- 
mony of  many  careful  observers. 

TJiird. — Regions  otherwise  non-malarial  may  have  ma- 
larial poison  brought  to  them  by  the  waters  of  rivers  w^hich ' 
have  their  source  in,  or  flow  through,  malarial  districts. 

Examples  of  this  kind  are  found  along  the  banks  of  our 
Western  rivers,  where  are  developed  some  of.  the  most  per- 
nicious types  of  this  fever ;  while  in  places  only  a  short 
distance  from  these  rivers  it  is  unknown. 

This  can  be  accounted  for,  if  we  accept  the  theory  that 
malarial  poison  has  been  transmitted  through  waters  having 
their  source  in,  or  running  through,  malarial  districts. 

Fourth. — Non-malarial  regions  may  be  rendered  malarial 
from  poison  transmitted  by  the  wind. 

There  has  been  considerable  discussion  as  to  whether  this 
poison  can  be  transmitted  in  such  a  manner,  and  if  it  can 
be,  to  what  distance.  I  find  no  reliable  account  of  its  trans- 
mission over  a  greater  distance  than  four  and  three-quarter 
miles. 

Malarial  fever  broke  out  in  the  crew  of  a  ship,  which  was 
anchored  Just  four  and  three-quarter  miles  from  shore  where 


T^rnoDurTiox.  11  :i 

this  f(>vor  was  provailiiii:;.  No  cases  wcn^  on  boaid  wlwn  tlio 
anchor  was  cast,  nor  did  any  of  the  crew  <;o  on  siioiv.  So 
long  as  the  wind  blew  from  th«;  sliij)  towards  shore,  tli(? 
crew  remained  wrll.  l)iit  wlim  the  wind  cliaiiLred  its  direc- 
tion and  hlew  from  llie  shore  Inwards  tlie  slii]),  witliin  six 
days  from  tlie  time  of  cliange,  cases  of  well-developed 
malarial  fever  ajipeared  on  board.  This  seenied  to  prove 
conclnsively  that  the  fever  was  bronght  to  the  ship  })y  the 
wind. 

The  wind  may  also  carry  malarial  i)oison  up  ahmg  the 
sides  of  mountains,  to  an  elevation  of  one  thousand  feet; 
some  writers  say  no  liigher  than  six  hundred  feet. 

American  writers  give  no  account  of  its  being  earned 
higher  than  six  hundred  feet,  while  some  German  writers 
give  well  authenticated  cases,  which  show  that  it  must  have 
been  carried  to  the  height  of  one  thousand  feet. 

I  have  thus  far  called  your  attention  to  some  of  the  more 
im])ortant  conditions  which  are  necessary  to,  or  seem  to 
favor,  the  development  of  this  malarial  poison.  You  have 
seen  that  certain  of  these  conditions  are  absoluti'ly  neces- 
sary for  its  production.  I  have  also  noticed  most  of  the 
conditions  which  render  its  development  more  active. 

I  will  now  ])riefly  consider  some  of  the  circumstances 
whicli  are  inimical  to  its  production. 

First. — Hif/h  latitude.  In  this  country  malarial  poison 
is  not  generated  in  higher  latitude  than  that  of  Quebec. 
The  limit  of  its  development  is  03''  north  latitude,  and  57° 
south  latitude.  Between  these  two  parallels  of  latitude, 
both  on  the  eastern  and  western  hemispheres,  malarial 
fevers  may  be  developed  ;  the  nearer  the  ajjproach  t(j  the 
equator,  the  more  severe  the  type.  They  do  not  prevail 
over  the  entire  region  embraced  between  these  ])arallels  of 
latitude,  but  it  is  possible  for  them  to  be  developed  at  any 
point  where  the  altitude  is  not  too  great. 

Second. — High  elcration  is  another  condition  inimical  to 
its  development.  As  a  rule  (as  I  have  already  stated),  it  is 
not  generated  above  an  elevation  of  one  thousand  ft.'et  a])ove 
sea  level. 

There  are,  however,  some  reniaikable  excejitions  ro  this 
8 


114  JIALAKIAL  FEVERS. 

rule.  We  find  recorded  cases  of  malarial  fever  wliicli  have 
been  developed  upon  plateaus  among  the  Pyrenees,  at  an 
altitude  of  o, 000  feet.  I  have  already  referred  to  the  fact 
that  malarial  poison  is  much  more  readily  developed  in 
marshes  which  have  a  cla}'"  or  lime-stone  bottom,  than  in 
those  which  have  a  sandy  or  porous  substratum.  Among 
the  Pj^renees,  there  is  a  marsh  which  has  a  clay  bottom, 
and  there  malarial  poison  is  developed  which  is  very  per- 
sistent. 

Tltird. — Drainage  is  another  means  which  diminishes, 
and  in  certain  conformations  of  soil  entirely  destroys  mala- 
rial generation.  In  the  majority  of  marshes,  this  generation 
can  be  arrested  or  prevented  by  free  drainage.  Yet  there 
are  marshes  upon  which  millions  have  been  expended  in 
drainage,  which  still  remain  pestiferous. 

Perhaps  it  is  possible  to  clrain  the  Jersey  flats  so  as  to 
render  them  non-malarial  in  their  character,  but  it  is  hardly 
probable  that  this  change  can  be  effected,  for  they  have  a  clay 
bottom,  and  contain  both  salt  and  fresh  water,  conditions 
which  I  have  stated  are  most  favorable  to  malarial  genera- 
tion. Years  of  labor  and  large  expenditures  of  mone}^  have 
been  bestowed  upon  the  Pontine  marshes  to  render  them 
non-malarial,  yet  they  are  as  pestiferous  as  they  were  two 
thousand  years  ago. 

Fourth. — Cold  is  a  powerful  agent  in  arresting  malarial 
generation.  I  care  not  how  jDestiferous  a  region  may  have 
been,  if  only  for  one  night  the  temperature  fall  below 
the  freezing  point,  nothing  more  need  be  feared  in  that 
region  from  malaria,  until  the  average  temperature  shall 
have  again  reached  60°  F.  This  law  holds  in  all  malarial 
districts.  In  these  districts,  after  the  temperature  has  fallen 
below  the  freezing  point,  persons  may  have  the  fever,  but  it 
is  the  result  of  previous  poisoning. 

Again,  the  generation  is  less  rapid  and  the  poison  is  less 
virulent  during  the  day  than  at  night.  This  is  the  uniform 
testimony  of  those  who  have  seen  most  of,  and  written 
most  on  malarial  diseases.  It  is  also  almost  universally 
conceded  that  malarial  districts  are  most  pestiferous  during 
months  when  the  atmosphere  is  hot  and  dry,  with  little  or 


TX'iiionuc-rroN'.  115 

no  wind,  osporially  wlicn  iliis  state  of  atmospli.-iv  lias  been 
pit'cedcd  by  lonir,  heavy  laiiis,  and  thai  tin*  vinili'iicc  of  tlio 
poison  is  greatly  diminished  as  soon  as  fresh,  strong  winds 
rlear  tlie  atnios])lu*re. 

1  have  called  yonr  attenlion  to  tlie  most  prominent  laws 
which  seem  to  govern  the  jtroduction  of  this  jxiisoii,  as  also 
T  have  endeavored  to  bring  befori?  you  thos(?  conditions 
which  i'avoi-,  as  well  as  (hose  which  hinder  or  prevent  its 
development.  The  ([n(>stion  now  arises,  ITow  does  malarial 
poison  gain  enhance  into  the  human  bod}'  i 

The  most  reasonable  view  is  that  this  is  effected  through 
the  res])ired  air.  Certain  facts  seem  to  show  that  it  may- 
be introduced  through  the  intestinal  ti'act  with  the  food 
and  water.  There  stnMns  to  be  scarcely  a  d()ul)t  but  that 
it  ma}'  be  taken  into  tlie  stonuich  with  foul  drinking-water. 
Accejiting  this  view,  in  certain  localities  it  has  come  to  be 
tlu^  practice  to  add  whiskey  to  the  drinking-water  to  de- 
stroy the  ])oison,  but  there  is  no  reason  for  the  belief  that 
whiskey  has  any  such  power. 

When  this  })()ison  has  once  been  introduced  into  the  cir- 
culation, it  undoubtedl}'  has  the  power  of  reproducing  it- 
self, hence  the  entire  system  is  affected.  From  this  fact, 
which  must  be  regarded  as  well  established,  those  who 
regard  this  poison  as  a  living  organism,  claim  that  these 
organisms  may  reproduce  themselves  indefinitely,  but  their 
existence  has  never  yet  been  demonstrated.  It  has  also 
been  claimed  that  certain  races  are  mon^  exem])t  than  others 
fi'oiu  malarial  fever,  also  that  there  ai-e  idiosynciasies  of 
constitution  wlii<'li  i-ender  ceitaiii  individuals  exempt  from 
diseases  of  this  ty})e,  for  in  (li>liicts  where  these  fevers  ]»re- 
vail  there  are  persons  who  never  have  the  fever. 

It  seems  to  me  that  this  exemption,  both  in  races  and 
individuals,  is  duo  to  the  greater  physical  })ower  of  the 
individual,  which  enables  him  to  resist  these  noxious  atino- 
s})heric  influences. 

In  a  district  where  malarial  inlluencrs  j)i'evail,  the  weak 
and  anaunic  are  the  most  liable  to  be  attacked,  and  tdl  those 
influences  which  tend  to  lower  vitiilily,  and  to  I'lnhi-  feel)l(! 
the  powers  of  resistance,  must  be  regarde(l  as  sp-'cial  ju-edis- 


116  MALARIAL   FEVERS. 

posing  causes.  A  strong  man  may  resist  for  a  long  time, 
while  the  old  man  and  the  child  very  quickly  succumb  to 
the  influence  of  the  poison.  Women  are  more  suscep- 
tible than  men  to  its  influence.  You  can  no  more  account 
for  the  fact  that  one  person  can  take  in  large  doses  of  mala- 
rial poison  without  being  eft'ected  by  it,  while  another  is 
affected  by  a  very  small  quantity,  than  you  can  account 
for  the  fact  that  one  individual  can  take  large  quantities  of 
alcoholic  stimulants  without  showing  any  signs  of  intoxica- 
tion, while  a  very  small  quantity  will  intoxicate  another 
individual,  supposing,  in  both  instances,  the  individuals  to 
have  apparently  an  equally  vigorous  constitution. 

Some  claim  that  wdien  an  individual  has  been  poisoned 
with  malaria,  complete  recovery  never  takes  place  ;  others 
claim  that  even  with  the  worst  cases  recovery  is  possible.  My 
own  experience  leads  me  to  believe  that  when  an  individual 
has  once  sufl'ered  from  malarial  poisoning,  he  is  much  more 
susceptible  than  one  who  has  never  been  so  poisoned.  For 
instance,  an  individual  suffers  from  one  or  more  attacks  of 
intermittent  fever,  and  then  removes  from  a  malarial  dis- 
trict, if  that  person  again  enters  a  malarial  region,  he  is 
much  more  likely  to  suffer  from  malarial  fever,  however 
slight  the  poisoning  may  be,  than  if  he  had  never  suffered 
from  its  effects.  Some  unknown  physical  change  has  taken 
place  which  renders  him  a  fit  subject  for  malarial  manifesta- 
tions upon  the  slightest  exposure. 

This  brings  us  to  the  doctrine  of  the  latency  of  malarial 
poison  in  the  human  body.  This  is  an  interesting  and  at 
the  same  time  a  very  obscure  subject. 

That  there  is  a  period  of  incubation,  or  rather  that  a  cer- 
tain time  elapses  between  the  exposure  and  the  develop- 
ment of  malarial  fever,  seems  to  be  a  settled  question.  For, 
often  a  long,  always  a  short  period  elapses  before  new- 
comers in  malarial  districts  have  their  first  attack  of  the 
fever  ;  sometimes  the  poison  remains  latent  until  after  they 
have  removed  from  the  district.  It  is  on  this  basis,  the 
latency  of  the  malarial  poison,  that  the  relapses  can  be 
accounted  for,  which  occur  in  those  who,  having  lived  in  a 
malarial  district,  remove  and  remain  in  a  non- malarial  one. 


INTltonUCTIOX.  117 

Tliis  it'awalci'iiiii--  of  tlu^  iii:il:iii:il  j)(>is()ii  may  (Ifjiciid  upon 
a  varict}-  of  causes,  sudi  as  takiiii,^  cold,  ovor-futiguc,  sud- 
den changes  of  tenii)eratui(',  etc.,  etc. 

\Vhetlier  an  individual  who  lias  once  been  tlioroughly 
l)oisoned  with  malaria  can  <'ver  become  entirely  fre*^  from 
its  influence,  is  still  an  unsettled  (juestion. 

From  my  own  observation,  1  am  convinced  that  it  is  im- 
possible to  bring  (Mie  wholly  from  under  tlie  influence  of  the 
poison  while  lie  remains  in  a  malarial  district,  though  he 
ma}^  become  exempt  from  its  influence  (witliout  the  re- 
awakening causes  already  mentioned,  taking  cold,  etc.,  etc.), 
if  he  remains  beyond  the  malarial  belt. 

Undoubtedly,  you  have  often  heard  it  stated  that  an 
individual  may  become  so  acclimated  as  to  resist  malarial 
influences,  and  live  for  a  long  time  in  a  malarial  district 
without  suffering  any  evil  effects  from  it. 

There  can  be  no  question  but  that  those  living  in  such 
districts  suffer  less  from  the  acute  manifestations  of  the 
poisoning  than  do  new-comers.  But  the  truth  is,  those 
changes,  which  we  call  chronic  malarial  affections,  are 
constantly  going  on  in  those  who  are  supposed  to  be 
acclimated. 

The  comparison  still  holds  good  in  reference  to  those 
addicted  to  the  use  of  alcohol.  We  might  say,  tluy  are 
becoming  acclimated  to  its  use.  The  fli-st  dose  a  person 
takes  may  make  him  drunk,  but  after  a  time  repeated  and 
larger  doses  fail  to  produce  this  effect.  Malaria  acts  like 
any  other  i)oison  :  after  a  time  the  system  reaclu.'s  a  certain 
degree  of  tolerance. 

This  toh'iance  of  malaria,  or  immunity  from  its  manifes- 
tations, amounts  to  nothing  more  than  the  accommodation 
of  the  system  to  its  prevailing  influence. 

Let  the  acclimated  })erson,  as  he  is  called,  be  taken  sick 
with  any  active  form  of  disease,  such  as  diphtheria  or 
pneumonia,  and  it  usually-  proves  fatal,  not  that  there  is 
anything  unusually  severe  in  the  di])htlieria  or  ]>neu- 
monia  which  brings  about  the  fatal  termination,  but  death 
is  due  to  the  fact  that  the  system  is  charged  with  malarial 
poison. 


118  MALARIAL   FEVERS. 

Tliere  is  anotlier  point  in  tliis  connection  concerning  which 
I  wish  to  say  a  few  words. 

It  has  been  clahned  by  very  intelligent  and  careful  ob- 
servers that  phthisical  developments  are  prevented  by 
malarial  poisoning.  After  having  carefully  investigated 
this  subject,  I  am  convinced  that  the  eifect  of  the  poison  on 
the  human  organization  is  to  predispose  it  to  phthisical 
developments.  The  milder  climate  and  the  less  frequent 
changes  in  temperature  in  the  malarial  regions  accounts 
for  the  fact  that  there  is  less  phthisis  in  those  regions  than 
in  the  cold,  non-malarial  regions.  The  malarial  districts 
in  the  northern  portion  of  the  temperate  zone  have  the 
highest  death  rate  from  phthisis.  If  we  accept  the  fact 
that  the  larger  number  of  cases  of  phthisis  are  catarrhal  in 
their  origin,  and  that  catarrhal  pneumonia  is  more  likely  to 
be  developed  in  those  who  are  broken  down  from  the  pro- 
longed influence  of  malarial  poisoning,  you  will  be  prepared 
to  understand  how  chronic  malarial  iDoisoning  predisposes 
to  phthisis.  In  quite  a  number  of  instances  I  have  traced 
the  beginning  of  phthisical  development  to  this  cause. 

There  are  many  other  j)oints  of  interest  closely  connected 
with  this  subject  of  malarial  poisoning,  but  which  have  no 
special  connection  with  the  class  of  diseases  which  we  are 
about  to  study. 


LECTURE    XI. 


SIMPLE   INTERMITTEXT    FEVER. 

Morhtd  Anatomy. — Etiology. — Sy77i2)to///s. — Differential 
Diofjuosis. — Prognosis. — Treatment. 

I  iiAVK  spoken  of  tlie  origin  of  inal:iiiul  fever,  and  of  cer- 
tain known  facts  concerning  the  development  of  the  mala- 
rial poison,  and  to-day  will  commence  the  history  of  this 
class  of  fevers.     First  in  order  is  simple  intermittent  fever. 

Like  typhoid  fever,  simj^le  intermittent  fever  is  met  with 
in  all  i)arts  of  the  world,  althongh  the  region  of  its  develop- 
ment may  be  said  to  be  limited  by  63°  north  latitude  and 
57^  south  latitude.  Within  these  parallels  it  is  the  more 
]n-evalent  the  nearer  you  approach  the  equator. 

MoKHiD  Anatomy. — The  anatomical  changes  wliicli  take 
place  in  this  fever  are  few  and  require  only  a  passing  notice. 
In  regard  to  the  blood-clianges  we  are  without  any  reliable 
chemical  or  micr()Sco])ical  data.  We  iind  none  of  those 
changes  in  the  blood  u  liicli  are  present  in  the  more  severe 
forms  of  infectious  disi-asc,  neither  do  we  find  those  which 
are  jnvsent  in  tin*  jx'niicious  ty])e  of  mahirial  fever,  such  as 
pigmentation  and  inaik'-d  (liniiiiiitioii  in  ihe  red  globules. 
IL'  th»'  ft'ver  has  continued  for  a  long  time  tln-re  may  be 
slijiht  diminution  in  tlie  number  of  the  red  globules  and  a 
decrease  in  the  iibriu  <.r  tlx'  blood;  but  these  changes,  to  a 
great  extent,  are  due  to  the  high  temi)t'i;i(ure  which  attends 
its  paioxysms.  The  only  constant  jjatlioloixical  lesion  of 
sinijdi'  iiiti-nnii  fi'iii  fever  is  congestion  of  i  li.'  intfi-ual  or- 
gans.    Tht,'  s]»l('eu   and   liver  are  always  more  or  less  en- 


120  SIMPLE  INTERMITTENT   FEVER. 

larged,  but  the  enlargement  is  due  to  simple  liypersemia ; 
no  structural  changes  occur  in  these  organs  until  the  inter- 
mittent paroxysms  have  been  often  repeated,  and  the  mala- 
rial poisoning  has  been  of  long  duration.  There  is  also 
more  or  less  hypenemia  of  the  kidneys  and  the  mucous 
membrane  of  the  intestines,  but  it  is  not  attended  by  any 
signs  of  gastric  or  intestinal  catarrh.  As  yet  no  one  has 
been  able  to  prove  that  any  structural  change  takes  place 
either  in  the  nerve  tissue  or  in  any  other  tissue  of  the  body ; 
nor  from  the  structural  or  functional  disturbances  that  oc- 
cur during  the  fever,  has  any  one  been  able  to  find  a  satis- 
factory answer  to  the  question,  why  it  is  a  paroxysmal  and 
not  a  continued  fever  1  By  some  German  writers  it  is 
claimed  that  during  a  paroxysm  of  the  fever  white  blood- 
globules  are  very  rapidly  developed  ;  but  the  question  arises, 
how  is  this  to  be  demonstrated  1  I  have  never  seen  a  post- 
mortem examination  on  one  who  had  died  during  a  simple 
intermittent  paroxysm,  and  have  never  heard  of  such  a 
death  unless  the  patient  had  some  intercurrent  disease.  As 
I  have  already  stated,  all  the  appreciable  lesions  of  simple 
intermittent  are  those  of  hypersemia. 

Etiology. — At  my  last  lecture  this  subject  w^as  brought 
to  your  notice.  All  agree  that  simple  intermittent  fever  is 
due  to  malarial  poisoning,  and  that  the  poison  is  introduced 
into  tlie  body  either  through  the  lungs  or  through  the  in- 
testinal tract. 

Whatever  tends  to  depress  the  mental  or  physical  powers 
of  an  individual  renders  him  more  susceptible  to  malarial 
influences,  and  consequently  these  depressing  influences 
must  be  regarded  as  predisposing  causes.  Among  these 
may  be  included  intemperance,  exposure  to  night  air,  exces- 
sive fatigue,  bad  hygiene,  and  a  long  list  of  like  debilitating 
causes. 

Symptoms. — This  fever  is  a  paroxysmal  disease,  of  differ- 
ent types,  according  to  the  period  of  time  between  the  par- 
oxysms. 

The  Ji7^st,  and  most  common,  is  the  quotidian  type,  in 
which  the  paroxysm  occurs  every  day,  and  there  is  an  in- 
terval of  twenty-four  hours  between  the  paroxysms. 


SVMI'T(»\[^.  121 

Seco7if1,  yow  liavc  tlic  h  rliim  t  \  jw,  in  wliicli  (hi-  ]):ir()X- 
ysm  occurs  every  tliird  day,  with  an  iiiti-ival  of  l'oity-ti;^ht 
hours  Ix'twciMi  lilt'  })aroxysMis. 

7V///V/,  3()U  liavf  tlic  (/muliiii  type,  in  which  the  piirox- 
ysiu  occurs  ever}'  fourth  <hiy,  with  an  interval  of  three  days 
or  seventy-two  liours  between  the  ])aro\ysnis. 

These  are  the  re<;ular  and  nioiv  coninniii  types  of  inter- 
mittent fever.  ^fedical  writers  make  mention  of  other 
types,  which,  although  irregular,  are  uni[uestional)ly  modi- 
fications of  those  ah-eady  mentioned.  Among  these  is  what 
is  dt'scribed  as  rhu/hlc  quotidian,  in  whicli  two  paroxysms 
occur  daily.  Usually  one  paroxysm  is  severe,  the  other 
mild  :  the  severer  one  generally  occurs  in  the  morning,  the 
milder  in  the  afternoon  or  evening.  There  is  also  a  donhle 
tertian,  in  which  a  paroxysm  occurs  daily,  but  it  differs 
from  the  quotidian,  as  the  paroxysms  that  resemble  each 
other  occur  at  intervals  of  forty-eight  hours.  For  instance, 
the  paroxysm  of  to-day  is  characterized  by  tiie  occurrence 
of  a  severe  chill  and  mild  fever  ;  to-morrow  it  is  character- 
ized by  a  short  chill  and  severe  fever ;  the  following  day 
there  occurs  the  severe  chill  and  mild  fever,  as  on  the  first 
day. 

Some  writers  describe  a  form  of  intermittent  fever  in 
which  the  paroxysm  occurs  on  the  seventh,  fourteenth, 
twenty-first  day,  etc.,  with  an  interval  of  seven  days  be- 
tween the  parox^'sms. 

The  t3'])es  most  fi-e(juently  met  with  are  the  quotidian, 
tertian,  and  quaitan. 

In  the  quotidian  variety  tin-  ]>ai()xysm  occurs  in  the 
morning,  in  the  tertian  it  occurs  about  noon,  while  in  the 
quartan  it  occurs  in  the  afternoon  or  evening.  The  dura- 
tion (jf  the  paroxysm  varies  with  the  ty])e  of  the  frvcr.  In 
the  quotidian  it  lasts  fiom  eight  to  t<Mi  hours,  in  the  tertian 
it  lasts  from  six  to  eight  hours,  in  the  quartan  fi'om  four  to 
six  hours. 

There  are  many  excejttions  to  these  rules,  but  it  is  a 
question  whether  we  w(.)uld  have  them  if  the  disease  was 
permitted  to  run  its  course  without  tivatnit-nt. 

Paroxysms. — A  ])aroxysm  of  intermittent  fevt-r  has  three 


122  SIMPLE  INTERMITTENT  FEVER. 

stages,  namely,  the  cold  stage,  the  Ttot  stage,  and  the  stage 
of  sweating.  In  most  cases  these  are  easily  distinguished 
the  one  from  the  other. 

In  the  true  type  of  intermittent  fever  we  have  regular  in- 
tervals between  the  paroxysms  of  fever. 

Let  us  notice  some  of  the  phenomena  which  attend  one 
of  these  paroxysms. 

After  the  patient  has  suffered  for  a  certain  length  of  time 
with  pain  in  the  head,  a  sense  of  languor,  and  some  nausea, 
he  passes  into  the  cold  stage. 

Cold  Stage.— His  passage  into  this  stage  is  first  marked 
by  a  sensation  of  coldness  along  the  back,  which  soon  extends 
to  the  extremities,  and  an  uncomfortable  sensation  of  cold- 
ness gradually  creeps  over  the  entire  body.  The  skin  be- 
comes shrivelled,  the  finger  ends  and  lips  become  blue,  tlie 
face  is  pale,  the  eyes  are  sunken,  chills  rapidly  follow  each 
other,  the  teeth  begin  to  chatter,  any  voluntary  motion  is 
attended  by  trembling,  nntil  finally,  as  one  chill  after  an- 
other in  quick  succession  passes  over  the  bod}^,  the  patient's 
teeth  chatter  so  that  it  can  be  heard  some  distance  from  the 
patient,  and  there  is  a  shaking  of  the  entire  body. 

The  surface  of  the  body  becomes  rough,  the  blood  seems 
to  recede  from  it,  and  the  skin  assumes  the  appearance 
described  as  goose-sldn  or  cutis  anserina.  The  temperature 
of  the  surface  of  the  body  is  lower  than  normal,  but  if  you 
place  the  thermometer  in  the  axilla  or  under  the  tongue 
you  will  find  that  the  temperature  has  reached  104°  F.  or 
105°  F.  The  voice  of  the  patient  is  weak  and  husky,  the 
respirations  are  rapid,  short,  and  sighing,  but  the  mind  re- 
mains clear.  The  urine  is  increased  in  quantity,  and  paler 
than  normal,  and  there  is  frequent  desire  to  empty  the  blad- 
der. Usually  these  symptoms  are  present  from  half  an 
hour  to  two  or  three  hours  ;  the  length  of  time  depends 
upon  the  severity  of  the  case. 

After  the  cold  stage  has  continued  for  a  longer  or  shorter 
period,  the  patient  begins  to  have  flashes  of  heat  alternating 
with  the  chilly  sensations.  Usually  these  are  first  felt  at 
the  extremities,  but  they  rapidly  extend  over  the  whole 
body,  and  the  hot  stage  is  established. 


SYMPl'OMS.  1 23 

Hot  Stage.— The  skin,  in  tliis  stage,  is  no  long(>r  sliiiv- 
elled,  but  becomes  red,  swollen,  iind  turgid,  and  tlifie  is  a 
recession  of  the  blood  from  the  central  organs  to  the  sur- 
face of  tlie  body.  That  the  temperature  is  elevattnl  can  be 
ascertaiUL'd  sim])ly  by  laying  the  hand  upon  the  surfac.  If, 
however,  you  })lace  the  thcrmonit'tcr  in  the  axilla,  in  most 
cases  you  will  Iind  the  temperature  has  reached  1UG°  or  107° 
F.  The  thirst  is  very  much  increased.  The  comfortable 
sensation  which  the  patient  experienced  while  i)assing  from 
the  cold  to  tlie  hot  stage  has  given  way  to  great  restlessness 
and  uneasiness,  the  patient  tossing  from  side  to  side,  with 
face  Hushed,  and  eyes  red  and  liery.  Sometimes  herpetic 
vesicles  appear  about  the  mouth.  The  heat  and  thirst  be- 
come intense,  the  tongue  becomes  dry,  the  carotids  pulsate, 
the  radial  pulse  becomes  firmer  and  more  rapid  than  in  the 
cold  stage,  and  nausea  is  now  a  marked  symptom.  It  may 
have  been  present  in  the  cold  stage,  but  in  the  hot  stage 
nausea  and  vomiting  become  the  pronnnent  sym])toms.  As 
a  rule  the  symptoms  of  this  stage  last  from  half  an  liour  to 
two  hours.  In  exceptional  cases  they  may  continue  for  a 
much  longer  time.  As  I  have  already  stated,  the  ordinarj' 
duration  of  a  paroxysm  of  a  quotidian  intermittent  is  from 
eight  to  ten  hours;  that  of  a  tertian,  from  six  to  eight 
hours  ;  and  that  of  a  quartan,  from  four  to  six  hours.  It  is 
possible,  especially  in  those  forms  of  malarial  feviM-  in 
which  the  poisoning  is  intense,  for  the  hot  stage  of  a  cpio- 
tidian  to  continue  twelve  hours.  There  is  no  condition  in 
which,  for  the  time,  you  have  more  intense  fever  than  in  the 
hot  stage  of  intermittent  fever.  The  urine,  which,  during 
the  cold  stage,  was  abundant  and  of  pale  color,  now  be- 
comes highl}^  colored  and  scanty.  Not  unfrequently  it  is 
almost  suppressed  during  the  hot  stage.  Comi)lete  sup- 
pression of  urine  occurs  only  in  the  pernicious  type  of  the 
disease.  When  the  fever  has  continued  for  a  longer  or 
shorter  time,  a  slight  moisture  ai)pears  upon  the  forehead 
which  gradually  spreads  over  the  entire  liody,  and  the  pa- 
tient becomes  bathed  in  a  profuse  perspiration.  lie  is  now 
in  the  sweatinfj  staff e. 

Sweating  Stage. — As  this  stage  comes   on  the  former 


12-i  SIMPLE    IXTEKMITTENT   FEVER. 

restlessness  and  uneasiness  passes  away,  and  a  feeling  of 
comfort  comes  to  the  patient  as  the  perspiration  makes  its 
appearance.  The  temperature  rapidly  falls  ;  the  pulse  rap- 
idly diminishes  in  frequency  and  force ;  the  pulsation  of 
the  carotids  ceases  ;  the  face  assumes  its  normal  appear- 
ance ;  the  congestion  of  the  conjunctiva  disappears ;  and 
the  patient  rapidly  passes  from  a  high  state  of  fever  into 
one  in  which  he  falls  asleep,  and  awakens  after  a  period 
ranging  from  one  to  three  hours,  with  a  sense  of  exhaustion. 

Interval. — During  the  interval  between  the  paroxysms  at 
first  the  patient  may  feel  perfectly  well,  but  if  there  is  a 
frequent  repetition  of  the  paroxysms,  there  will  very  soon 
be  a  marked  loss  of  vitality  ;  he  becomes  pale  and  feeble, 
and  all  the  symptoms  of  malarial  cachexia  are  present. 
There  will  be  more  or  less  of  a  jaundiced  hue  to  the  skin, 
enlargement  of  the  spleen  and  liver,  and  pigmentation  of 
the  tissues.  It  is  true  that  many  paroxysms  of  simple  in- 
termittent may  occur  before  any  such  general  disturbance 
of  the  health  of  the  patient  manifests  itself  ;  yet,  in  the  in- 
terval between  the  paroxj^sms,  we  cannot  call  the  patient's 
condition  one  of  perfect  health. 

Usually,  in  the  quotidian  type,  the  day  previous  to  the 
development  of  the  first  paroxysm,  unnoticed  by  the  pa- 
tient, there  is  a  •  slight  rise  in  temperature,  perhaps  from 
99i°  F,  to  103°  F.  At  the  same  time  he  experiences  a  sense 
of  lassitude,  and  is  disinclined  to  make  any  exertion,  either 
mental  or  physical.  The  temperature  commences  to  rise 
in  the  morning,  and  by  noon  it  has  reached  its  maximum 
height  ;  then  it  begins  to  fall,  and  by  evening  it  may  have 
fallen  to  nearly  its  normal  standard.  Thus  the  course  of 
the  temperature  is  quite  characteristic,  and  may  be  summed 
up  as  a  rapid  ascent,  a  short  and  intense  stationary  period, 
and  critical  defervescences  constituting  the  paroxysms,  with 
a  perfectly  normal  temperature  in  the  interval.  The  fol- 
lowing day  another  rise  in  temperature  will  be  noticed  ; 
now  the  rise  does  not  occur  in  the  morning,  but  after  mid- 
day, perhaps  so  late  as  in  the  evening.  Usually  in  the 
quotidian  type  of  intermittent  fever  tlie  highest  tempera- 
ture is  reached  a  little  earlier  each  da}"  ;  if  it  is  reached  a 


TUFFKni.XTIAT.    DrAdXOSIS.  125 

little  later,  you  may  Ix'  (■•■rtaiii  that  the  ffvcr  is  briiii;  iiiod- 
ilied  or  ooiitrollnl  by  tn'atiuciit.  Wf  liave  wliat  ar<'  ralh'd 
anticipalhuj  and  pontpaninij  jtaroxysnis.  When  iIk'  i»ai-- 
oxysin  comes  on  a  little  earlier  each  day,  it  is  called 
mificipddiHj.  and  indicates  that  the  fever  is  not  bt'in^ 
controlled;  when  il  conies  on  at  a  later  hour  eacli  day  in 
indicates  the  ("ever  is  being  cont lolled.  :iiid  is  called  a  ])ost- 
l)onini:;  intermittent. 

The  ty])es  of  intermittent  fever  which  occur  most  fre- 
quently in  temperate  climates  are  the  quotidian  and  the 
tertian.  With  us  the  quotidian  is  most  frequent.  In  those 
who  liave  suffered  rej^eatedly  from  intermittent  fever,  the 
disease  is  liable  to  ruu  an  irregular  course,  th<»  pai-oxysms 
occurring  on  irregular  days,  and  with  irregular  intervals. 
In  children  this  fever  shows  certain  deviations  from  the 
ordinary  course.  The  paroxysms  may  be  ushered  in  by 
convulsions,  or  by  a  period  of  stupor.  Children  rarely  liave 
the  distinct  chill.  After  a  period  varying  from  ten  minutes 
to  hair  an  lioui-,  we  have  the  hot  stage  of  regular  intermit- 
tent fever  coming  on,  with  all  its  attendant  phenomena. 
The  intermissions  are  rarel}^  complete.  The  child  loses  his 
appetite  and  flesh,  becomes  irritable,  and  has  a  pale,  waxen 
look,  and  suffers  from  gastric  and  inti-stinal  disturbances, 
and  the  intermittent  very  soon  lapses  inlso  a  remittent. 

Differential  Diagnosis. — The  differential  diagnosis  of 
simple  intermitte!it  fever  is  never  very  difficult.  There  are 
only  two  diseases  which  are  liable  to  be  mistaken  for  it, 
namely,  remittent  fever  and  pya?mia.  It  is  readily  dis- 
tinguished from  remittent  fever,  for  in  remittent  fever  there 
is  never  a  comi)lete  intei-mission.  whereas  in  intermittent 
there  is  always  a  period  in  which  there  is  no  fever.  A  care- 
ful thermometrical  observation  for  twenty-four  hours  settles 
all  question  in  regard  to  it.  In  remittent,  tin'  temperature, 
when  at  its  lowest  point  during  tlie  remission,  is  on«'  oi-  two 
degrees  higher  than  normal,  while  in  intermittent  the  tem- 
perature reaches  the  normal  standard  during  the  intermis- 
sion. 

There  is  also  a  r<>gidar  development  of  the  paroxysm  in 
intermittent,  which  does  not  oc'-ur  in   remittenf.     In  lemit- 


126  SIMPLE  INTERMITTENT   FEVER. 

tent  usually  you  have  but  one  chill,  while  in  intermittent  a 
chill  precedes  each  paroxysm  of  fever. 

Tlie  diagnosis  between  intermittent  fever  and  pyaemia  is 
also  readily  established.  In  pyemia,  there  is  no  complete 
intermission  in  the  fever  and  no  regularity  in  the  time  of  its 
occurrence,  or  in  the  severity  of  the  paroxysms.  In  both 
diseases  you  have  chills,  fever,  and  sweats,  but  in  py?emia 
the  chill  is  short ;  rapid  shivering  is  followed  by  a  prolonged 
and  very  high  fever,  and  this  is  followed  by  profuse  sweat- 
ing. The  sweating  of  intermittent  is  never  so  profuse  as  that 
of  pyaemia,  and  in  the  latter  disease  there  is  no  regularity  in 
the  development  of  the  phenomena,  while  in  intermittent, 
the  nature  of  the  paroxysms,  and  the  time  of  their  occur- 
rence, can  be  predicted  with  great  certainty.  The  principal 
element  in  the  clinical  history  of  pyaemia  is  a  steady,  high 
temperature,  without  any  intermission.  When  the  sweat- 
ing comes  on  the  temperature  may  fall  one  or  two  degrees, 
but  it  never  approaches  the  normal  standard,  and  there  is 
never  a  distinct  intermission. 

It  is  much  more  difficult  to  make  a  differential  diagnosis 
between  pyaemia  and  remittent  fever  than  between  pyaemia 
and  intermittent.  Hereafter  this  will  be  more  fully  con- 
sidered. The  same  thing  may  be  said  in  regard  to  the 
hectic  fever  of  phthisis. 

Prognosis.— The  prognosis  in  simple  intermittent  fever 
is  good.  If  continued  for  only  a  short  time,  there  will  be  no 
tissue  changes  to  prejudice  the  life  of  the  patient. 

The  possibility  of  the  development  of  malarial  cachexia 
must  enter  into  the  prognosis.  When  this  occurs  the  case 
is  more  than  one  of  simple  intermittent  fever  ;  there  is  en- 
larged spleen,  enlarged  liver,  and  pigmentation  of  tissues. 

Treatment. — The  treatment  of  intermittent  fever  is  di- 
vided into  that  for  the  paroxysm  and  that  for  the  interval. 
The  treatment  for  the  paroxysm,  in  most  cases,  is  simply  to 
render  the  patient  as  comfortable  as  possible  while  passing 
through  its  various  stages.  At  one  time  it  was  proposed  to 
tourniquet  the  limbs,  so  as  to  prevent  congestion  of  internal 
organs,  and  thus  arrest  the  paroxysms. 

Again,  it  has  been  proposed  to  apply  cold  to  the  surface 


TKKAI  MKNT.  \'27 

of  tho  body,  foi-  flic  ])urj)()sr  of  <;lving  a  sliock  (o  tlic  iu'V-> 
vous  sysli'iu.  ;iii(l  in  tluir  niaiiiH'i-  to  .-n-i-cst  llic  ])ar()xysni. 
To  :icc()iiii)lis|i  iliis.  l)y  covcriiii;-  (he  siiirnrc  of  tlic  })ody 
with  siii;i]ii-ms,  in  ordrr  lo  iiriinh-  llic  ciiliiinfuis  siiifaci?, 
lias  also  hiM'ii  ))i-o](o-.'(l.  Soiiif  lia\c  claiiiit'cl  tli;il  if  an  in- 
dividual is  lifcMiulit  fully  undri-  tin-  inllnrnci;  of  alcohol  tii.' 
regular  (li'V.Iojmicnt  of  ;i  paroxysm  can  be  ])n'vented. 
Again,  it  has  hci-n  (•hununl  that  opium,  given  in  full  doses 
at  the  usual  linic  foi' the  recurrence  of  the  paroxysm,  lias 
power  to  ])revent  it. 

Experience  does  not  lead  me  to  accept  any  of  tliese  state- 
ments. It  is  true  that,  in  some  instances,  a  sudden  shock  to 
the  nervous  system  may  prevent  tlie  developin<'nt  of  an 
intermittent  paroxysm  when  thi'  ])aroxysms  have*  Ix'come  a 
liabit. 

If  there  is  anytliing  in  the  entire  list  of  means  (eitlier  re- 
medial or  hygienic),  tliat  I  have  named,  which  has  i)ower 
to  prevent  the  full  development  of  a  paroxysm,  it  is  o})iuin. 
When  this  is  adniinisterrd  liypodermically,  early  in  tlie> 
cold,  stage,  it  will  diminish  the  severity  of  tlie  cold  and  hot 
stages.  Whether,  in  the  treatment  of  the  milder  forms  of 
intermittent  fever,  the  combination  of  oiuuin  with  ([uinine 
is  advisable,  is  still  an  unanswei'ed  question,  thougn  it  seems 
to  me  that  in  such  cases  much  comfort  can  be  alTorded,  and 
the  patient  be  much  h'ss  injuriously  affected,  by  the  parox- 
ysm, if  opium  be  administered  in  moderate  doses. 

Patients  with  intermittent  fever  should  be  kepi  in  bed 
during  the  entire  paroxysm,  however  mild  it  may  be. 
During  the  cold  stage,  cover  them  with  l)laid':ets,  surround 
them  with  bottles  of  hot  water,  and  let  them  drink  freely  of 
hot  water.  All  tliese  means  will  hasten  the  hot  stage  of  the 
disease.  Bui-ing  the  hot  stage,  the  extra  clothing  and  ex- 
ternal heat  should  be  gradually  removed,  and  cold  instead 
of  hot  drinks  should  be  administered.  1  f  nausea  and  vomit- 
ing are  present  in  this  stage,  you  will  lind  that  oi>iuiii.  ad- 
ministered hypodermically,  alTords  great  relief. 

When  the  patient  reaches  the  sweating  stage,  h-t  him 
alone;  within  a  few  hours  lif  will  l)e  cnliicly  ivjicved,  and 
in  a  state  of  convalescence.    The  question  now  aiises.  What 


128  SIMPLE  inteemitte:n^t  fever. 

treatment  sliall  we  adopt  during  the  interval  to  prevent  t1ie 
occurrence  of  another  paroxysm  ?  If  possible  to  prevent  it, 
never  allow  a  patient  to  have  a  second  intermittent  par- 
oxysm ;  for  if  the  s^'stem  once  becomes  accustomed  to  these 
paroxysms,  they  will  be  repeated  upon  the  slightest  provo- 
cation. You  will  frequently  find  this  to  be  the  case  with 
persons  who  for  a  long  time  have  not  been  subjected  to 
malarial  influence,  and  yet  upon  the  least  nervous  excite- 
ment or  fatigue  will  have  a  paroxysm. 

Let  me  impress  upon  you  to  prevent,  if  possible,  the 
occurrence  of  a  second  paroxysm  of  intermittent  fever. 

The  great  remedy  at  this  time  is  the  sulphate  of  quinine. 
Skilf all}"  used,  it  is  all-powerful  to  accomplish  this  result. 
How  and  why  it  arrests  the  development  of  these  parox- 
ysms I  do  not  know.  We  simply  know  the  fact.  Our 
knowledge  of  its  antiperiodic  power  is  purely  empirical. 
There  is  much  difference  of  opinion  as  to  the  mode  in  which 
it  should  be  administered.  In  commencing  the  treatment  of 
a  case  of  intermittent  fever,  after  the  occurrence  of  the  first 
paroxysm  it  is  always  safe  to  assume  that  the  fever  is  of  the 
quotidian  type.  At  least  thirty  grains  of  quinine  should  be 
administered  between  the  termination  of  the  one  paroxysm 
and  the  hour  when  another  is  to  be  expected.  The  first  dose 
of  ten  grains  should  be  given  towards  the  close  of  the  sweat- 
ing stage,  and  twenty  grains  about  two  hours  before  the 
time  of  the  expected  paroxysm.  If  possible,  give  the  qui- 
nine in  solution.  If  there  should  be  sufficient  irritability 
of  the  stomach  to  cause  the  rejection  of  the  quinine,  it  may 
be  administered  hypodermically,  or  by  enema.  Three  grains 
administered  hypodermically  has  about  the  same  antiperi- 
odic power  as  ten  grains  administered  by  the  stomach.  If 
you  succeed  in  preventing  the  occurrence  of  a  second  par- 
oxysm you  have  accomj)lished  much  for  your  patient. 

Having  prevented  the  occurrence  of  a  second  paroxysm, 
it  is  important  that  a  moderate  degree  of  cinchonism  should 
be  maintained  for  a  number  of  days,  by  the  daily  adminis- 
tration of  quinine  in  moderate  doses.  About  two  hours 
before  the  time  of  daj^  at  which  the  first  paroxysm  occurred, 
from  ten  to  fifteen  grains  of  quinine  should  be  daily  admin- 


TUKATMENT.  129 

istercd.  You  iiiii>l  not  now  piTiuit  yoiii-  jtMiifnl  lo  jtass  en- 
tirely i'roiii  iiinlcryoiir  olist'ivalioii.  Direct  him  lovisil  yoii 
one  numth  from  tin-  (/<t(c  <>/ f/n'/irsl  paroxi/sin^  for,  alt liou^li 
he  may  not  have  had  a  IVesh  iiiahiiial  exjxjsure,  there  will  he 
a  stroni;  ti'iidcncy  at  I  ids  tiiuc  lo  a  re})etitioii  of  the  parox- 
ysm, and  it  is  of  importance  tliat  your  ])atient  at  tluit  time 
sliould  he  amiin  l)rou,i;]it  fully  undei'  llie  inlluence  of  the 
c[uinine.  If  it  is  p(.)ssibh»  for  jour  patient  to  remove  from  a 
malarial  district  you  will  be  almost  certain  to  })reveiit  a 
seeoiid  paroxysm. 

If,  however,  you  do  not  see  your  ])ati<'nt  in  his  first  par- 
oxj'sm,  and  lie  lives  in  a  malarial  district,  sulphate  of  qui- 
nine, administered  in  tlie  manner  I  have  just  recommended, 
may  only  prevent  for  a  time  the  return  of  the  })aroxysm, 
and  even  complete  cinchonisni  may  fail  to  control  it.  You 
should  now  very  carefully  examine  the  case,  in  order  to  as- 
certain if  there  is  not  some  condition  present  which  inter- 
feres with  the  antiperiodic  action  of  the  quinine,  such  as 
hepatic  or  splenic  hyper^emia.  AVhen  careful  percussion 
shows  that  the  liver  and  sple<'n  are  increased  in  size,  even 
after  the  administration  of  full  doses  of  quinine,  you  will 
often  find  that  the  administration  of  full  doses  of  calomel 
with  the  quinine  will  increase  the  antiperiodic  power  of 
the  latter,  and  thus  diminish  the  jxTcussion  area  of  these 
organs. 

Occasionally,  when  full  doses  of  quinine  combined  with 
calomel  have  failed  to  prevent  a  recurrence  of  a  paroxysm, 
I  have  noticed  an  unusual  excitement  attending-  its  devel- 
opment, and  believing  from  this  circumstance  that,  owing  to 
individual  idiosyncrasies,  the  malarial  ])oison  had  a  more 
than  usiuil  irritating  effect  \\\)o\\  the  nervous  sj'stem,  I 
have  accomplished  the  desired  result  by  administering  full 
doses  of  opium  with  the  quinine.  In  fact,  if  the  i)alient 
is  of  a  highly  sensitive,  nervous  oigani/ation,  f  neverallow 
a  second  paroxysm  to  jiass  without  administering  a  full 
dose  of  0})ium  before  the  time  when  its  return  is  t(^  be  ex- 
pected. In  all  those  cases  which  are  called  obstinate,  ascer- 
tain why  you  have  failed  to  c(»ntrol  the  disease  by  the  use 
of  quinine. 


130  SIMPLE  INTERMITTENT   FEVER. 

I  rarely  have  administered  arsenic  in  simple  intermittent 
fever.  If  I  fail  to  control  the  fever  with  quinine,  aft(.n'  I 
have  reduced  splenic  and  hepatic  congestion,  controlled 
nervous  irritability,  and  increased  nutrition  by  the  adminis- 
tration of  iron  and  the  moderate  use  of  stimulants,  I  never 
succeed  with  arsenic.  In  some  of  the  chronic  forms  of  mala- 
rial manifestation,  I  have  found  arsenic  of  great  service, 
but  never  in  simj)le  intermittent  fever. 

Other  means  employed  in  the  treatment  of  this  fever  will 
be  spoken  of  in  connection  with  pernicious  fever. 

Masked  Intermittent. — In  this  connection  I  would  in- 
vite your  attention  for  a  few  moments  to  a  form  of  inter- 
mittent fever,  which  by  some  writers  has  been  designated 
masJced  intermittent  fever.  For  example,  to-day  a  patient 
has  a  regular  intermittent  paroxj^sm,  but  to-morrow,  instead 
of  its  recurrence,  perhaps,  he  suffers  from  the  most  intense 
neuralgia.  This  neuralgia  ma}^  have  its  seat  in  the  inter- 
costal or  in  the  sciatic  nerve,  or  perhaps  more  frequently  in 
the  frontal  portion  of  the  ophthalmic  branch  of  the  tri- 
gemini  nerve.  Some  one  nerve  becomes  involved  and  no 
other  seems  to  be  affected. 

In  some  cases,  an  intense  hemicrania  takes  the  place  of 
the  paroxysm. 

As  a  rule,  these  neuralgias  have  distinct  intermissions, 
and  so  come  to  be  regarded  as  masked  forms  of  intermittent 
fever. 

Instead  of  a  neuralgia,  your  patient  may  have  an  attack 
of  asthma,  or  an  attack  of  indigestion.  During  the  past 
year  I  have  seen  several  cases  of  intermittent  dyspepsia. 
The  patient,  after  having  had  one  or  two  distinct  intermittent 
fever  paroxysms,  or  perhaps  only  a  slight  chill,  fever,  and 
sweat,  has  suffered  severely  from  indigestion,  colicky  pain 
in  the  bowels,  and  symptoms  resembling  those  of  perito- 
nitis. Diarrhoea,  dj^senter}^,  and  sometimes  h^ematuria  and 
apparent  suppression  of  urine,  may  take  the  place  of  a  dis- 
tinct intermittent  fever  paroxysm. 

Again,  your  patient  may  have  a  single  well-defined  chill, 
or  even  two  chills  followed  by  most  intense  hemicrania, 
and  then  have  no  more  for  a  long  time,  but  sooner  or  later 


TREATMENT.  I'M 

hv  will    liavf  a  wcll-ilrlincd    iiitninil  N'lil    )):ir()X3'siii  wliidi 
will  i-cvt'al  the  n-al  iiaLuiv  (d"  the  discasr. 

Soiiictiim-s  I  his  roi-iu  of  iiitcriiiittt'nt  fever  instead  ol"  beintr 
:i  t|ii"iidiaiK  a  Icrtiaii,  or  a  .luaitaii.  may  be  one  in  which 
the  paioxvsius  are  developed  every  sixUi  or  seventJi  day.  1 
niiuht  rereryoii  lo  other  types  of  this  fever,  which  we  nii^^ht 
♦•all  masked  iiiiermii  lent,  Imi  which  in  their  develojmient 
do  not  i)re.sent  the  regular  ])heiiomena  (jf  a  fully  developed 
paroxysm. 


LECTURE    XII. 


SIMPLE    REMITTENT    FEVER. 

Morbid  Anatomy.  — Etiology.  — Symptoms.  — Differential 
Diagnos  is .  — Prognos  is . 

This  morning  I  shall  commence  the  history  of  Simple 
Remittent  Fever,  the  second  in  my  list  of  malarial  fevers. 

This  is  a  co7itinued  fever,  with  diurnal  exacerbations. 
It  is  known  by  different  names,  such  as  Southern,  AVestern, 
African,  Continued,  Bilious,  Acclimative,  and  Remittent 
Fever, 

The  term,  Remittent  Fever,  is  more  generally  accepted, 
and  the  one  which  I  shall  adopt. 

Morbid  Anatomy. — In  many  respects,  the  anatomical 
lesions  of  remittent  fever  resemble  those  of  intermittent 
fever,  yet  there  are  certain  points  of  difference  with  which 
it  is  important  that  you  should  become  familiar.  These 
differences  are  rather  in  degree  than  in  kind. 

Unquestionably,  both  these  types  of  fever  are  the  result 
of  malarial  poisoning ;  therefore,  we  may  exj^ect  the  same 
diminution  of  the  red  globules  and  the  same  changes  in  the 
fibrin  of  the  blood  in  remittent  that  we  have  noticed  in  pro- 
longed intermittents.  Yet  there  are  other  changes  in  the 
blood,  which  we  usually  find  present  in  the  former,  that 
are  of  quite  rare  occurrence  in  the  latter,  namely,  the  pres- 
ence of  free  pigment-granules.  These  pigment-granules 
are  met  with  in  some  of  the  pernicious  forms  of  intermit- 
tent fever ;  but,  in  all  cases  of  well-developed  remittent 
fever,  they  are  present  at  some  time  during  the  progress  of 


:M()i;iun  axatomv.  1^-^ 

the  disease.  This  j)iuiii('iilati()ii  is  due  to  tli-'  li.-iMn.'iloidiii 
wliicli  lias  ils  (>riL;iii  in  liu'  liMMiio,ii;l()l)iii  wliicli  has  Ix'cii 
liberated  froiu  ihe  bhxxl-coi-pusch'S  williiii  I  hi'  lilood-vcssels, 
and  Mh'ii  (h'Vch>iH'd  in  ihr  licpioi-  san,i;-iiiMis.  This  coloring 
matter  may  remain  eiili.-r  wilhiii  the  hlo()d-coi'i)iis(d(*s, 
which,  after  a  time,  become  hansronii'd  into  ])igment- 
irranules,  or  i-emain  free  in  ihe  lliiid  iiortioii  of  th«'bh)od. 
or  inliltiale  tlie  adjacent  cells  and  tissues.  ll  may  be 
transformed  into  granular  or  ciystalline  li;ematoidin. 

Till'  s/>Jv('n  is  not  so  nnudi  eidarged  in  n'lnittent  as  in 
inteiiuittent  fever,  and  the  increasi^  in  size  seems  to  be  of 
a  diU'erent  natur(\  The  enlargement  is  evidently  the  result 
of  congestion,  and  the  organ  sometimes  presents  very 
nearly  the  sanui  a})i)t>arance  as  it  ]iresents  in  typhoid  fever, 
except  that  there  is  more  pigmentation  i)resent,  which  is 
rarely  present  in  a  typhoid  spleen. 

There  are  also  structural  lesions  found  in  the  liver,  in 
the  stomach,  and  in  the  intestines,  which  are  not  i)resent 
in  intermittent  fever.  The  liver  is  not  very  much  increased 
in  size,  and,  in  color,  is  of  a  bronze  hue.  The  princii)al 
change  is  in  color,  which  is  uniform  throughout  its  entire 
substance.  This  varies  in  degree  in  different  types  of  the 
disease,  and  in  different  cases  of  the  same  type.  The 
peculiar  color  is  due  to  pigmentation  of  the  liver  tissues, 
and  varies  according  to  the  amount  of  pigment  deposited. 
Pigmentation  may  occur  in  other  tissues  of  the  body,  but 
not  to  the  same  extent  as  in  the  liver.  On  a  microscopical 
examination  of  the  liver  tissue,  pigment  is  found  through- 
out its  entire  structure — not  onl}'  in  the  hepatic  cells,  but 
in  the  nu-lei  of  these  cells  and  in  the  walls  of  the  blood- 
vessels. 

This  discoloration  is  of  such  uniform  occurrence  that  it 
has  been  recognized  in  different  countries  and  by  different 
writers  as  the  characteristic  ])athological  lesion  of  remittent 
fever.  Consequently  you  will  hud  in  your  books  that  the 
*■'' bronzed  lire/'''  is  spoken  of  as  the  ciiaracteristic  lesion  of 
this  fever.  Occasionally  you  may  have  the  same  ])athologi- 
cal  lesion  in  inl'Tinit  h'lil  ami  pi'rnicious  fevr.  but  this  is  so 
seldom,  and  ils  presence  is  so  coii->taiit    in    iciiiillfnt    fevei*. 


134  SIMPLE   EEMITTENT  FEVER. 

that  if  3^011  meet  with  it  at  an  autopsy  yon  may  venture 
n])on  the  diagnosis  of  remittent  fever. 

Stomach. — You  will  find  the  mucous  membrane  of  the 
stomach  more  or  less  congested,  thickened,  and  softened. 
In  this  respect  the  disease  is  somewhat  allied  to  typhoid 
fever.  You  will  find  similar  changes  also  in  the  mucous 
membrane  of  the  intestines  ;  it  is  more  or  less  congested, 
and  presents  very  much  the  appearance  seen  when  a  mod- 
erately severe  catarrhal  inflammation  is  present.  The  Peye- 
rian  patches  are  usually  enlarged,  and  quite  frequently 
present  the  "shaven  beard"  appearance.  In  some  cases 
there  are  ulcerations,  not,  however,  as  extensive  or  of  the 
same  nature  as  the  ulcerative  processes  of  typhoid  fever. 
The  mesenteric  glands  are  not  enlarged,  and  there  is  none 
of  that  granular  infiltration  in  the  glands  so  noticeable  in 
typhoid  fever.  There  is  only  a  simple  hypersemia,  entirely 
due  to  a  catarrhal  inflammation.  Thus  you  notice  in  tak- 
ing up  the  history  of  each  of  these  fevers,  that  while  each 
one  is  a  distinct  disease,  we  find  many  things  that  are  com- 
mon to  all  of  them.  There  is  in  all  some  pathological 
change  which  seems  to  link  them  together. 

The  same  changes  may  occur  in  the  muscular  tissues  of 
the  body,  which  are  met  with  in  typhus  and  in  typhoid 
fever,  and  they  are  claimed  by  some  to  be  the  result  of 
prolonged  high  temperature  ;  yet  in  remittent  fever  the 
temperature  rises  higher  than  in  t3^phoid,  while  these  mus- 
cular degenerations  are  of  rare  occurrence,  and  less  exten- 
sive when  present.  The  more  we  stud}^  these  fevers  the 
more  disposed,  it  seems  to  me,  will  we  be  to  attribute  these 
granular  degenerations  to  something  besides  high  temper- 
ature. 

The  most  important  characteristic  change,  and  perhaps  the 
only  one,  in  all  malarial  fevers,  is  the  change  which  takes 
place  in  the  blood-globules. 

Etiology. — The  great  predisposing  and  exciting  cause  of 
this  fever  is  malarial  poisoning.  There  can  be  no  question 
but  that  the  same  malarial  poison  which  gives  rise  to  inter- 
mittent fever  can  produce  a  remittent  fever.  In  other 
words,  we  have  remittent  passing  into  intermittent  fever, 


T'.TIOI.OCV.  i:>.') 

and  int(>rniitt('nt  passing  info  nMnitf<Mif  fi'vcr.  AVIiUp  it  is 
jtossiblt'  for  this  to  occur,  as  a  iiilc  the  two  disriiscs  do  not 
prevail  in  the  same  h)cality  at  the  sann-  liiuc.  Eii(lt'iiiit<  of 
one  form  may  occur  and  Ix-  foUowcd  by  endemics  or  sj)o- 
radic  cases  (tf  the  other  form.  In  some  h)calities  remittent 
fever  is  almost  tlie  oidy  form  of  mahirial  disease,  intermit- 
tent fever  only  occasionally  occurring. 

Tiiere  is  ])rol)al)ly  no  form  of  endemic  disease,  the  ge(.- 
gr:ij»lii(:il  lioundaries  of  which  an?  more  extensive  than 
those  of  remittent  and  inlermittent  fever.  With  certain 
exceptions  they  may  l)e  said  to  encircle  tlie  earth  by  a 
broad  belt,  ])arallel  with  the  equator,  limited  by  03°  north 
latitude,  and  by  57°  south  latitude.  The  boundarii^s  of  this 
belt  are  quite  irregular,  now  approaching  the  line  of  the 
tropics,  now  receding  from  it. 

The  remittent  fever  which  occurs  within  the  northern  or 
southern  limits  of  this  belt  is  much  less  severe  than  that 
which  occurs  in  the  tropical  regions.  From  the  localities 
in  which  this  fever  ])revails  it  would  seem  that  a  higher 
average  temperature  is  required  for  its  development  than  is 
required  for  the  development  of  intermittent  fever.  In  cer- 
tain portions  of  this  immense  tract  cases  of  remittent  fever 
are  never  seen  ;  especially  is  this  the  case  at  a  distance  from 
the  equator,  whih.'  in  the  trojjical  regions  the  places  of  ex- 
emption are  comparatively  few. 

As  I  have  already  stated,  a  remittent  ffn'er  during  its 
convalescence  may  become  an  intermittent,  and,  conversel}-, 
an  intermittent,  either  from  new  exposure  to  malarial  in- 
fluences or  to  the  influence  of  high  tenqxMature,  may  be- 
come a  remittent.  From  this  fact  the  conviction  is  forced 
upon  us  that  under  differing  circumstances  both  these 
types  of  fever  may  be  developed  from  a  conunon  malarial 
poison.  Usually  certain  atmospheric  changes  will  have 
taken  i)lace  to  change  the  tj^pe  of  the  fever.  They  rarely 
prevail  endemically  at  the  same  time.  For  instance,  inter- 
mittent fever  may  prevail  early  in  the  season,  but  as  the 
season  advances,  and  the  temperature  ranges  higher,  the 
fever  which  prevails  will  assume  the  remittent  type. 

Some  claim  that  each  of  these  two  forms  of  fever  has  a 


136  SIMPLE  KEMITTEXT   FEVER. 

distinct  malarial  poison,  but  I  bc4ieve  the  difference  to  be, 
not  in  kind,  but  in  degree.  Tliere  are  certain  circumstances 
which  predispose  one  person  more  thananother  to  an  attack 
of  remittent  fever.  For  instance,  those  who  go  from  a  non- 
malarial  district  into  one  where  remittent  fever  is  prevailing 
are  more  likely  than  those  who  live  in  the  infected  district 
to  have  this  fever. 

Remittent  fever  is  governed  by  the  same  laws  in  its  de- 
velopment that  govern  the  other  forms  of  malarial  fever. 

It  prevails  along  the  banks  of  rivers ;  the  miasm  which 
produces  it  may  be  conveyed  by  the  wind ;  it  occurs  in 
marsh}'  regions  where  there  is  but  little  water.  When  the 
same  localities  in  which  intermittent  prevails  are  exposed 
to  a  higher  degree  of  temperature,  remittent  fever  may 
be  developed.  These  laws  have  already  been  sufficiently 
considered  under  the  head  of  malarial  poisons. 

Symptoms. — The  ushering-iu  symptoms  of  remittent  fever 
are  usually  more  marked  than  those  of  any  other  form 
of  continued  fever. 

The  most  constant  as  well  as  the  most  urgent  of  the  pre- 
monitory sj'mptoms  is  oppression  in  the  epigastrium.  This 
may  be  present  for  forty-eight  hours,  or  even  a  longer  time, 
previous  to  its  development.  There  is  also  a  certain 
amount  of  lassitude,  nausea,  and  loss  of  appetite,  and 
with  these  feelings  uneasiness  and  perhaps  pain  in  the  head 
and  limbs.  There  is  ver}'  much  the  same  feeling  of  general 
discomfort  that  precedes  the  development  of  typhoid  fever. 
But  the  disease  does  not  come  on  gradually,  as  does  tj^phoid 
fever,  but  abruptly,  usually  with  a  chill.  There  is  no  ques- 
tion as  to  when  the  patient  began  to  be  sick.  The  cold 
stage  is  neither  so  complete  nor  so  long  continued  as  it  is  in 
intermittent  fever  or  pneumonia. 

It  is  of  importance  that  you  remember  this  peculiar  fea- 
ture. During  the  chill  the  thermometer  will  indicate  a 
temperature  two  or  three  degrees  above  the  normal.  With 
the  chill  there  is  a  most  intense  headache,  pain  in  the  back 
and  limbs.  Following  the  chill,  there  is  fever,  during  which 
the  temperature  rises  very  rapidly.  The  fever  increases  in 
severity,   and,   within  twelve  hours  from  the  time  of  its 


SYMTTftMS.  1*37 

roiiimrMic-MiuMit  flic  fciiip.'iatiii-.' will  li:ivo  n^aclicd  loH"  or 
inc."  V.  Asm  miI<-.  iIk-  rliill  is  iim|  of  so  lon<;  dunitioii  as 
ihr  riiili  of  iiii.'imiltciit  frvn-,  iicilli.M-  docs  it  besin,  lik«'  it, 
In'  civi'piiiL;-  (luwii  ilir  lt;ick  and  uiadiiallv  <'Xt('iuliii.ii;  over 
till' l>()dv,  but  tln'iv  is  LiriH'ial  (..Idiicss  ovci' the  iSiiri'act' ol' 
til.'  Ixxh  at  tilt'  vriy  coiiiint'iM-cmriit  of  the  cliilly  sensation. 
Aerain,  tlu'iv  is  iioi  that  tiviiiuli»iisiicss  and  sliakin^^  of  tlii> 
body,  ntMtlior  dial  clialt.'iinu- of  tli.'  Iccih,  wliicli  is  so  frc- 
qucntly  (wpcrii'iiccd  in  intriniii  iriii  1V\.'|-.  In  a  few  words, 
til.'  cliill  of  ivniitlrnt  is  not  so  severe  as  tliat  of  intiTniittent 
fever. 

As  soon  as  the  t<iiij>crat iiii'  coiniuences  to  rise,  the  })nlse 
is  incn'as.'d  in  fiviiucncy,  and  perhaps  reaches  100  or  120 
beats  to  tin'  ininutt'.  The  face  becomes  Unshed,  but  not  so 
intensely  tbished  as  in  the  second  stage  of  intermittent 
fever.  The  eyes  are  usually  suffused,  and  the  conjunctiva 
is  somewhat  congested.  The  patient  is  restless,  tossing  in 
bed,  in  the  vain  search  of  an  easy  posture.  As  the  hot 
stage  ad^•an(■rs,  nausea  and  vomiting  are  always  present, 
and  the  sense  of  oppression  in  the  epigastrium  increases, 
which  is  not  relieved  by  vomiting. 

In  making  a  diagnosis,  remember  that  this  disease  is 
ushered  in  by  a  c/f/II,  followed  by  afcrrr,  which  is  accom- 
panied by  nausea,  vomiting,  and  gnnit  distress  in  the  epi- 
gastrium. 

We  have  nausea  and  vomiting  oecurring  in  intermittent 
fever,  but  it  is  not  so  persistent  and  distivssing  in  character 
as  the  nausea  and  vomiting  of  ivmittrnt.  Again,  there  is 
not  the  same  amount  of  ])ain  in  the  epigastrium,  for  in  the 
febrile  stage  of  remitttMit  fever  the  patient  suffers  from  it  to 
such  an  extent  that  quite  commonly  it  is  the  only  thing 
of  which  he  complains. 

Before  this,  thei-e  has  been  a  sen-.'  of  oppression  and 
perhaps  pain  in  the  epigastrium,  but  during  tiiis  period 
the  e])igastric  distress  is  very  great,  and  is  often  accom- 
])anied  by  the  most  extreme  tenderness  upon  ])ressure.  The 
material  first  vomited  sim])ly  consists  of  the  contents  of  the 
stomach,  next  follows  tin'  vomiting  <>f  n  gri'enish  matter, 
and  finally,  in  severe  cases,  even  of  simple  remittent  fever, 


138  SIMPLE  EEMITTEIS^T  FEVER. 

YOU  iTicay  have  a  slight  amount  of  black  vomit.  This 
resembles  the  black  vomit  of  j^ellow  fever.  The  quantity 
of  fluid  vomited  is  greater  than  the  quantity  taken  into  the 
stomach. 

Yomiting  of  stringy  mucus  tinged  with  green  is  always 
present  in  remittent  fever.  Sometimes  the  patient's  stomach 
rejects  everything  taken  into  it,  and  the  vomiting  is  accom- 
panied by  terrible  distress  in  tlie  stomach,  pain  in  the  head, 
and  general  disturbance  of  the  system. 

At  the  commencement  of  the  fever,  usually,  the  bowels 
are  constipated. 

The  symptoms  thus  described  go  on  increasing  in  severity 
for  ten  or  twelve  hours,  then  you  will  notice  a  slight  amount 
of  pei'spiration  upon  the  forehead.  In  a  short  time,  it  ex- 
tends over  the  entire  bod}^,  not  profuse,  but  a  slight  moist- 
ure upon  the  surface.  With  the  perspiration  will  be  a  fall 
of  one  or  two  degrees  in  temperature,  and  a  fall  of  ten  or 
twenty  beats  in  the  minute  rate  of  the  pulse.  The  thirst 
will  diminish,  the  vomiting  grow  less,  there  may  now  be 
ability  to  retain  fluids  taken  into  the  stomach,  and  the 
patient  falls  into  a  quiet,  refreshing  sleep,  and  is  relieved 
from  all  the  severer  symptoms  of  the  paroxysm.  If,  how- 
ever, you  will  place  the  thermometer  in  the  axilla,  you  will 
And  that  evidences  of  fever  still  exist,  and  although  there 
has  been  a  marked  decline  in  temperature,  it  does  not  reach 
the  normal  standard.  At  no  time  is  there  a  complete  in- 
terruption; the  fever  is  continuous.  This  is  termed  the 
period  of  remission.  At  the  same  time  on  the  following 
day  all  the  active  febrile  sjanptoms  return,  increased  in 
severity,  the  range  of  temperature  is  higher,  the  gastric 
disturbance  is  more  marked  and  severe,  the  countenance 
assumes  an  anxious  expression,  and  all  the  symptoms  are 
more  severe. 

This  return  of  the  severe  febrile  symptoms  constitutes 
what  is  called  the  exacerbation,  and  the  period  between  the 
time  when  the  fever  abates  and  the  development  of  the  ex- 
acerbation is  called  the  period  of  remission.  Remissions  and 
exacerbations  are  the  characteristic  symptoms  of  a  remittent 
fever  when  it  is  fully  developed,  at  which  time  a  morning 


SYMPTOMS.  I'AO 

remission  is  tlu-  rule,  tli()u,i!;li  tlio  tiiiic  of  the  first  paroxysm 
vai-ics.  If  the  cxaccrbiitioii  l)i'i:iMs  :it  noon,  it  will  usually 
decline  about  midniu-liL  :iii(l  lln'  nmission  will  last  until 
about  noon  the  next  iluy.  In  vt-ry  severe  cases  there  may 
be  a  double  exact^bation,  one  at  noon,  the  otlier  at  mid- 
night, the  remissions  being  in  tin'  t-vcning  and  morning. 
The  second  exacerbation  is  similar  to  tin-  jtiinmiy  in  its 
attendant  phrnomena,  except  that  it  is  niort*  seven'  and  of 
longer  duration,  ends  in  a  h'ss  profuse  perspiration,  and  tlie 
remission  is  not  so  well  marked  as  the  first. 

On  the  third  day,  at  about  the  same  houi-,  or  a  little 
earlier,  we  again  have  the  exacerbation,  which  has  a  still 
longer  duration,  is  of  greater  severity,  and  is  followed 
b}'  a  more  incomplete  remission.  If  the  disease  goes  on 
from  day  to  day,  the  remission  becomes  less  and  less  dis- 
tinct, and  the  case  becomes  dangerous  just  in  proportion  as 
it  loses  its  ])arox3'smal  character.  By  tli(;  end  of  the  first 
week  the  remission  can  no  longer  be  detected,  and  the  fin'er 
becomes  a  continued  fever,  without  any  marked  daily  vari- 
ation in  temperature  or  pulse.  As  the  remissions  become 
less  and  less  distinct,  with  each  returning  exacerbation  the 
tongue  becomes  more  and  more  parched,  sordes  collect 
"upon  the  teeth,  the  countenance  becomes  dull  and  heavy, 
distress  and  pain  in  the  e])igastrium  continues,  and  is  ac- 
companied by  tenderness,  although  the  senses  of  the  patient 
are  so  dulled  that  he  may  scarcely  complain  of  it  ;  the 
vomiting  is  not  so  constant,  and  is  of  a  less  distressing 
character ;  constipation,  which  was  probably  present  at  the 
commencement  of  the  fever,  has  now  given  way  to  diar- 
rhopal  discharges,  which  are  usually  of  a  brownish  color. 
With  the  diarrhopa  there  is  some  fulness  of  the  abdomen, 
and  some  local  tympanitis.  The  pulse  is  increased  in  fre- 
quency, and  has  p<'rhaps  leached  120  or  130,  is  small, 
thready,  and  feeble,  whih^  at  the  onset  of  the  diseases  it  was 
full  and  compressible.  The  patient  slips  down  in  the  bed, 
picks  at  the  Ix^d-clothes  ;  there  is  subsultus  and  diiriculry 
in  deglutition,  and  the  tongue  is  protruded  with  difliculty, 
as  in  the  severer  forms  of  typhoid  fever.  In  other  words, 
the  patient  has  passed  into  a  condition  closely  resembling 


140  SIMPLE   REMITTENT   FEVER. 

tliat  of  0110  wlio  lias  entered  tlie  tliird  week  of  a  typlioid 
fevei-,  with  tliis  exception,  there  is  no  eruption. 

The  diarrlia^a,  abdominal  disturbance  and  tympanitis, 
and  often  the  tenderness  over  the  ileo-cfRcal  region,  the 
typhoid  tongue,  and  the  low  muttering  delirium,  closely 
allies  this  stage  of  simple  remittent  fever  to  typlioid  fever  ; 
but  the  absence  of  the  rose-colored  spots  and  the  typical 
range  of  temperature  of  typhoid  fever  are  sufficient  to  dis- 
tinguish it  from  that  fever. 

After  these  typhoid  symptoms  have  continued  a  week  or 
ten  days,  if  the  case  is  to  terminate  in  recovery,  remissions 
recur  and  become  more  and  more  distinct,  until  finally 
there  is  no  exacerbation,  and  the  patient  passes  into  a  state 
of  convalescence.  If,  however,  a  fatal  termination  is  to 
take  place,  the  remissions  will  not  recur,  but  the  typhoid 
symptoms  will  become  more  marked,  and  the  patient  will 
finally  die  from  exhaustion  or  from  complications.  Of  all 
the  symptoms  which  attend  simple  remittent  fever,  nausea 
and  vomiting  are  the  most  constant  and  the  most  distress- 
ing. I  have  seen  patients,  after  the  temperature  had  fallen 
to  its  normal  standard,  suffer  for  weeks  from  gastric  dis- 
turbance, attended  by  more  or  less  jaundice. 

If,  in  the  progress  of  a  remittent  fever,  the  exacerbation 
occurs  a  little  earlier  each  day,  then  treatment  is  not  con- 
trolling it,  but  the  disease  is  gaining  ground  ;  the  fever  is 
then  said  to  be  anticipating,  and  you  may  be  almost  cer- 
tain that  the  disease  is  j)assing  from  a  distinct  remittent  to 
a  continued  remittent. 

If,  on  the  other  hand,  the  exacerbation  occurs  a  little 
later  each  day,  the  fever  is  said  to  be  postponing,  and  you 
may  be  sure  that  you  are  controlling  it,  and  that,  as  the 
remissions  become  longer,  the  exacerbations  will  become 
shorter  and  less  severe,  until  the  patient  reaches  complete 
convalescence.  The  thermometer  will  indicate  to  what  ex- 
tent the  disease  is  being  controlled. 

This  is  the  history  of  what  may  be  regarded  as  simple  re- 
mittent fever.  It  begins  with  a  chill,  is  followed  by  distinct 
exacerbations  and  remissions,  and,  if  not  controlled  by 
treatment,  becomes  a  continued  fever  ;   then,  after  a  week. 


SYMPTOMS.  141 

perluips  a  longer  time,  the  remissions  recur  again  until  con- 
valeseenee  is  established,  or  tlu'  tyi)hoi(l  sym])l()ms  Ix-coiue 
more  marked,  the  remissions  do  not  recur,  and  (h'ath  ensues. 

If  a  simple  remittent  fever  is  jtiotracted,  the  typhoid 
syn4)toms  whieh  are  develoj)ed  do  not  stamj)  it  with  a 
typh(.)id  character;  they  are  such  symptoms  as  are  liable 
to  occur  in  any  acute,  infectious  disease. 

Bilious  J{i:mittkxt  Feveu. — In  a  c<Mtain  ])roportion 
of  cases,  in  all  endemics  of  remittent  fever,  vomiting  of 
"bilious"  material,  iuu\  Jaundice  are  i)rom\nent  symptoms, 
the  skin  often  becoming  so  yellow  that  the  ])atieiits  ])re- 
sent  an  tippearance  similar  to  those  suilering  from  yellow 
fever ;  with  this  yellow  discoloration  of  the  skin  there  is 
an  unusual  tenderness  on  pressure  over  the  hei)atic  region. 
Under  such  circumstances  this  fever  has  been  named  "  bil- 
ious remittents 

By  some  of  the  older  writers  it  has  been  describcHi  as  an 
idiopathic  fever,  distinct  from  ]-eniittent  or  anj-  other  form 
of  malarial  fever.  Medical  literature,  however,  contains  no 
facts  in  support  of  such  a  view.  The  pathology  and  symp- 
tomatology of  the  fever  described  by  writers  undt^r  the  head 
of  hilious  remittent  fever  differ  in  no  respect  from  those  of 
simple  remittent,  except  that  the  fever  is  accomjxmied  by 
symptoms  of  more  than  usual  hepatic  and  gastric  disturb- 
ance. My  own  experience  leads  me  to  regard  it  as  a  form 
of  simple  remittent,  accom])anied  by  a  more  than  usually 
severe  gastro-hepatic  catarrh,  and  that  it  is  not  entitled  to 
a  separate  place  in  the  nosology  of  fevers. 

Infantile  Remittent  Fever. — In  this  connection  it  is 
perhaps  well  that  I  should  refer  for  a  moment  to  a  con- 
dition which  has  received  the  name  of  infantile  remittent 
fever. 

It  is  a  matter  of  everj'-day  experience  that  childien  are 
subject  to  certain  gastric  and  intestinal  di'rangmients, 
which  are  attended  b}-  more  or  less  fever,  which  is  veiy  apt 
to  assume  a  remittent  ty})e.  Such  fevers  cannot,  however, 
be  regarded  as  s})ecitic  diseases,  for  they  are  devtlo])ed 
independent  of  any  specific  fever  i)oison.  and  an-  (»nlv 
symptomatic  (jf  some  local    initati<»n.     There  is  a  form  of 


142  SIMPLE   REMITTENT  FEVER. 

mild  typlioid  fever  which  is  often  met  with  in  children, 
especially  in  the  autumn,  which  has  also  incorrectly  received 
the  name  of  infantile  remittent  fever.  In  this  class  of  cases 
the  usual  symptoms  of  typhoid  fever  are  so  modified  by 
age  that  the  fever  assumes  a  remittent  type.  The  presence 
of  rose-colored  spots,  and  the  characteristic  typhoid  lesion 
of  the  intestines,  will  determine  the  true  nature  of  these 
fevers. 

In  malarial  districts  you  will  meet  with  a  simple  malarial 
remittent  in  children,  which  does  not  differ  from  the  simple 
remittent  of  adults,  and  does  not,  therefore,  require  a  sepa- 
rate description.  Remittent  fever  in  children  is  more  liable 
to  be  followed  by  malarial  cachexia  than  in  the  adult. 

Differential  Diagnosis. — I  have  already  given  you 
the  rules  by  which  you  are  to  distinguish  a  simple  remit- 
tent from  a  simple  intermittent  fever,  and  it  is  not  necessary 
that  I  should  repeat  them. 

The  differential  diagnosis  between  remittent  and  typhoid 
fever  is  often  attended  with  difficulty,  if  the  patient  is  not 
seen  until  the  second  week  of  the  disease,  but  if  he  is  seen 
at  the  very  onset  of  the  fever,  it  is  hardly  possible  to  mis- 
take these  two  forms  of  fever  the  one  for  the  other.  The 
sudden  advent  of  a  remittent  is  in  marked  contrast  to  the 
slow  development  of  a  typhoid  fever.  Besides,  they  widely 
differ  in  the  range  of  temperature  during  the  first  week  of 
their  development.  In  remittent  there  is  a  distinct  remis- 
sion, and  you  need  not  doubt  as  to  the  type  of  fever  after 
the  first,  certainly  not  after  the  second,  remission  has  oc- 
curred. 

Again,  you  have  the  gastric  symptoms,  which  are  much 
more  severe  in  remittent  than  in  typhoid.  By  these  symp- 
toms alone  you  will  be  able,  in  many  instances,  to  make  a 
differential  diagnosis.  If,  however,  the  fever  has  been  pro- 
tracted to  the  third  week,  and  the  remissions  are  slight  or 
altogether  absent,  although  many  of  the  symptoms  of 
typhoid  fever  are  present,  the  absence  of  the  rose-colored 
spots  is  sufficient,  taken  in  connection  with  previous  history 
of  the  patient,  to  establish  the  diagnosis.  Should  you 
be  still  in  doubt,  place  a  drop  of  the  patient's  blood  under 


DIFFERENTIAL    DIAGNOSIS.  1  H 

the  microscope,  and  in  nearly  every  instance,  if  tlie  case  he 
one  of  remittent  fever,  jji^nni'iit  granules  will  be  seen,  which 
at  once  settles  the  question,  as  pignpMit  granules  are  not 
found  in  the  blood  of  tyi)lioid  fever  ])ati<'nts. 

Finally,  remittent  fever  isdeveloi)ed  only  in  malaiial  dis- 
tricts, and  there  can  be  no  difliculty  in  making  a  diU'cren- 
tial  diagnosis,  if  the  ]»atient  resides  in  a  non-nuilarial 
district,  and  is  not  known  to  have  been  exposed  to  mtilarial 
intlut'iu-i's. 

If  hemorrhages  occur  during  the  course  of  a  remittent 
fever,  the  blood  proceeds  from  the  mouth,  nose,  urinary 
organs,  and  bowels ;  while  in  the  advanced  stages  of 
typhoid  fever  it  rarely  occurs,  except  from  sloughing  of 
the  intestinal  glands. 

Simple  remittent  fever  may  be  distinguished  from  yellow- 
fever  by  its  high  range  of  temperature,  by  its  daily  exacer- 
bation and  remission,  by  the  presence  of  i)igment  in  the 
blood,  and  in  most  cases  by  the  absence  of  albumen  in  the 
urine,  which  is  ])resent  in  yellow  fever. 

In  ivmittent  fever,  hemorrhage  from  the  mucous  surfaces, 
especially  from  the  mucous  meml)rane  of  the  stomach,  is 
of  rare  occurrence,  while  in  yellow  fever  it  is  frequently 
present. 

Death  often  occurs  on  the  third  day  in  3-ellow  fever,  but 
in  the  severest  cases  of  remittent  fever  not  before  the  sev- 
enth day. 

Remittent  fever  nuiy  be  confounded  with  }.iy;eniia  and 
septicaemia,  but  their  differential  diagnosis  has  already  been 
sufliciently  considered  under  the  head  of  intermittent  fever. 
The  differential  diagnosis  between  remittent  and  typho- 
malarial  fever  will  be  considered  when  I  come  to  the  latter 
disease. 

PijoGNOsis. — The  ])rognosis  in  simple  remittent  fever 
is  good  ;  death  should  rarely  occur.  Even  cases  of  the 
severe  types  of  this  fever  should  terminate  in  recovery,  if 
skilfully  managed,  especially  if  they  are  seen  in  the  early 
stages  of  the  disease. 

You  must  remember  that  the  t^'pe  of  this  fever  varies 
very    much   according   to   locality.      The    remittent    fever 


144  SIMPLE    REMITTENT    FEVER, 

which  we  see  in  this  city  is  of  a  mild  type.  In  that  form 
which  prevails  in  many  parts  of  the  West  and  South  a 
fatal  termination  is  of  frequent  occurrence. 

There  is  a  type  which  soon  loses  its  remission,  and  be- 
comes a  pernicious  malarial  fever,  the  23rognosis  of  which  is 
unfavorable. 

The  prognosis  will  also  be  modified  by  the  condition  of 
the  patient  at  the  time  of  the  attack,  and  by  the  character 
of  the  epidemic  which  is  prevailing. 

I  have  already  indicated  the  symptoms  by  which  you  are 
to  determine  whether  recovery  is  to  take  place,  or  the  case 
is  to  terminate  fatally.  The  fact  that  the  exacerbation  is 
delayed  or  rendered  less  severe,  is  a  favorable  indication, 
unless  the  patient  becomes  more  and  more  overwhelmed  by 
the  malarial  poisoning,  which  condition  is  shown  by  a  high 
range  of  temperature  and  a  tendency  to  coma,  or  by  the 
jjatient's  passing  into  a  typhoid  state.  The  early  sub- 
sidence of  gastric  sjauptoms,  headache  and  a  decrease  in 
the  frequency  of  the  pulse,  are  favorable  signs.  Distinct 
remissions,  accompanied  by  moderately  free  perspiration, 
indicate  an  apj^roaching  favorable  change.  On  the  other 
hand,  if  the  fever  is  more  continuous  than  paroxysmal, 
with  a  pulse  becoming  daily  more  feeble  and  more  fre- 
quent, if  there  is  a  tendency  to  collapse  at  the  close  of  the 
exacerbations,  with  signs  of  extreme  exhaustion,  danger  is 
indicated. 

The  average  duration  of  this  fever  is  two  weeks. 

As  this  fever  varies  so  greatly  in  severity  at  different 
times  and  in  different  localities,  it  is  impossible  to  deter- 
mine its  average  rate  of  mortality. 


LECTURE   XIII. 


PERXTnorS  FEVER. 

Treatment  of  Simple  Remittent  Fever. — Morbid  Anatomy. 
— Etiology.  — Symptoms. 

We  shall  have  completed  the  history  of  simple  remittent 
fever  when  we  have  considered  its  treatment. 

Wlu^n  speaking  of  the  treatment  of  typhoid  fever,  I 
stated  to  you  tliat  the  fact  was  constantly  to  be  born*'  in 
mind  that  there  was  no  agent  by  means  of  wliich  we  could 
shorten  its  duration  or  arrest  its  development.  The  con- 
trary is  true  in  this  disease,  for  we  have  means  at  our  com- 
mand by  which,  in  the  majority  of  cases,  it  can  l)e  con- 
trolled, and  by  which,  in  all  instances,  its  duration  may 
be  very  much  shortened.  It  is  hardly  necessar}^  for  me  to 
speak  of  such  remedial  agents  as  blood-letting,  emetics, 
cathartics,  and  diaphoretics,  which  have  all  been  employed 
in  the  treatment  of  this  fever,  for  th(.^y  have  all  been  sup- 
planted by  a  single  remedy.  Perhaps  there  is  no  more 
difficult  lesson  for  a  young  practitioner  to  learn,  when 
brought  to  his  first  case  of  remittent  fever,  just  as  the 
patient  is  passing  into  his  first  exacerbation,  certainly  if  he 
has  reached  his  second,  than  to  restrain  himself  from  resort- 
ing to  a  vigorous  antiphlogistic  plan  of  treatment.  As  he 
feels  the  burning  heat  of  the  skin  and  the  full,  bounding 
pulse,  and  sees  the  flushed  face  and  congested  e\-e,  and 
listens  to  the  com])laint  of  intense  pain  in  the  head  and 
limbs,  of  unquenchable  thirst,  and  burning  pain  in  the 
epigastrium,  he  is  almost  impelled  to  resort  to  some,  or  all, 

of  the  more  vigorous  so-called  antiphlogistic  remedies  ;  but 
10 


146  PEKisricious  fevek. 

in  this  fever  it  is  true,  as  in  the  other  forms  of  fever  which 
have  been  engaging  our  attention,  that  these  violent  symp- 
toms are  cine  to  a  blood-poison  which  is  exerting  its  specific 
effect  npon  the  nerve  centres.  It  is  this,  not  an  inflamma- 
tory process,  that  we  have  to  contend  with.  Experience 
has  proved  that  this  poison  cannot  be  removed  from  the 
system  by  any  of  the  so-called  eliminative  methods  of 
treatment.  If  you  deplete  this  class  of  patients  to  any 
extent,  you  hasten  the  development  of  tliose  typhoid 
symptoms  which  are  especially  to  be  avoided.  Persons 
living  in  malarial  districts  are  never  up  to  the  normal 
standard  of  vigor,  and,  consequentl}^  are  in  a  condition  to 
be  affected  unfavorabh'  by  any  plan  of  treatment  or  by 
any  remedial  agents  which  shall  enfeeble  the  vital  powers. 

The  first  thing  to  be  done  in  the  successful  management 
of  this  fever  is  to  place  your  patient  under  the  best  possible 
hygienic  surroundings.  The  same  care  should  be  exercised 
in  the  arrangement  of  the  sick-room  as  has  already  been 
proposed  in  the  management  of  typhoid  fever.  Those  who 
have  seen  most  of  remittent  fever  in  its  severer  forms 
recommend  that  the  treatment  of  each  case  be  commenced 
by  administering  a  mercurial  purge.  They  claim  that  there 
is  always  more  or  less  engorgement  of  the  liver,  spleen,  and 
mucous  membrane  of  the  stomach  and  intestines,  and  that, 
so  long  as  these  organs  remain  in  this  condition,  no  plan  of 
treatment  will  be  successful. 

However  great  may  be  the  differences  of  opinion  in 
regard  to  this,  all  agree  that  the  sulphate  of  quinine  should 
be  used  in  the  treatment  of  this  fever.  Practitioners  differ, 
however,  as  to  the  mode  of  its  administration,  but  all  are 
united  in  its  use.  Some  maintain  that  it  has  greater  power 
over  the  disease  when  administered  in  small  doses,  re- 
peated at  short  intervals  ;  others  maintain  that  it  should  be 
given  in  one  or  two  large  doses  during  the  remission,  an 
hour  or  two  before  the  commencement  of  the  expected  ex- 
acerbations. Again,  others  claim  that  the  quinine  has  its 
greatest  power  over  the  fever  when  administered  during 
the  activity  of  the  febrile  excitement.  A  few  jenrs  ago  this 
snbject  was  carefully  studied  by  those  engaged  in  the  Eng- 


•ri;K  ATMF.XT.  147 

lish  Mcdiciil  Si'ivicc  in  Iiiili;i.  I'lidi'i-  tin'  diii-ciidii  i>('  ilic 
Stn;i!:(M»n-(Jfii('i-;il  in  tlml  (l(']>:ii-|m('iil  (iiiiiiiiic  wiis  iiiliiiiiiis- 
trvrd  at  (lill'crtMif  jx'iiods  in  the  coiii'sc  of  tli(>  fever.  I'<tr 
ex:iin])lf.  oin'  suru'eon  jj;:ivi'  (|iiiniiii'  :il  tin- cuniinfncrnn'iit 
of  the  exacerbation,  anotlxT  <;'ave  it  immediately  after  the 
exacerbation  had  |)asse(l  its  heii^ht  and  as  the  sweating 
stage  was  cominL;-  <iii.  another  gave  it  immediately  ])nM-(.'d- 
iiig  the  exacerbation,  and  others  gave  it  dm-ing  the  remis- 
sion. This  ])lan  was  adojjted  in  order  to  determine  with 
positiveness  when  the  smallest  amount  of  ([uinine  would 
have  tlie  greatest  controlling  elVect  over  the  lever.  Froin 
the  various  brandies  of  the  dei)artnient  reports  were  made 
to  the  Surgeon- General,  and  from  these  reports  the  conclu- 
sion was  arrived  at,  that  quinine,  administered  during  tlie 
time  of  the  exacerbation,  had  not  only  a  greater  inlluence  in 
diminishing  tlie  severity  of  the  disease,  but  it  also  more 
com])letel3^  controlled  the  fever,  and  more  markedly  short- 
ened its  duration  tlian  when  it  was  administered  during  the 
remission.  From  the  conclusion  arrived  at  from  their  re- 
ports, and  from  my  own  experience,  I  should  not  hesitate 
to  administer  quinine  at  any  time  during  the  period  of  ex- 
acerbation or  remission.  My  rule  is  to  give  ten  or  twenty 
grains  at  a  dose,  according  to  the  severity  of  the  fever,  and 
re])eat  it  ever}^  two  hours  until  cinchonism  is  produced. 
Wlien  cinchonism  is  reached,  although  the  fever  may  not 
be  controlled,  it  is  well  to  stop  its  administration  until 
twenty-four  hours  have  elapsed  ;  by  doing  this  you  will  be 
better  a])le  to  determine  the  antii)eriodic  ])ower  of  the 
drug.  If  you  find  that  the  exacerbations  do  nt)t  disa])pear, 
but  are  delayed  and  aie  less  severe,  you  may  be  sur»^  that 
you  are  controlling  the  fever.  If,  notwithstanding  this 
free  use  of  (piiniiK',  tln'  exacerbations  are  more  severe  and 
longer  in  duration,  and  the  remissions  h^ss  frequent,  and 
ty]>lioid  symptoms  are  manifesting  tliemselves,  stimulants 
may  br  demanded.  Even  large  doses  of  stimidaiits  may  b«' 
re([uired  to  sustain  the  ])atient  while  lie  is  ])assing  through 
this  ])eriod  of  the  disease. 

Remittent  f«*ver  is  not,  like  typhoid    fcvrr,  a   disease  of 
davs  or  weeks.      In  its  seveii'r  forms,   no  time  .should  be 


148  PEKNTCIOUS   FEVER. 

lost  while  waiting  for  tlie  action  of  cathartics  or  other 
remedial  agents  which  are  supposed  to  be  of  importance, 
but  you  should  at  once  commence  the  administration  of 
quinine.  When  the  disease  has  reached  its  second  or  third 
week,  and  there  is  no  evidence  that  the  patient  is  passing  on 
towards  recovery,  you  must  commence  a  second  time  the 
administration  of  large  doses  of  quinine  ;  in  this  way  you 
may  arrest  the  progress  of  the  fever.  If,  after  a  second  cin- 
chonism  is  produced,  the  fever  is  not  arrested,  you  must 
again  omit  for  a  few  days  the  administration  of  quinine ; 
then  repeat  the  large  doses  a  third  time.  It  is  much  better 
to  proceed  in  this  way  with  the  remedy  than  to  keep  your 
patient  in  a  continued  state  of  cinchonism.  It  is  not  neces- 
sary to  enumerate  the  long  list  of  drugs  which  at  different 
times  have  been  proposed  as  specifics  in  this  fever,  all  of 
which,  by  common  consent,  are  now  regarded  as  far  less  re- 
liable than  quinine.  The  important  thing  is  to  know  liow 
and  when  to  administer  quinine. 

There  are  certain  palliative  measures  which  it  is  some- 
times important  to  employ.  If  the  exacerbations  are  very 
intense,  the  headache  very  severe,  and  the  restlessness  or 
other  febrile  symptoms  are  not  relieved  by  full  doses  of 
quinine,  you  may  resort  to  the  use  of  cold  for  its  antipy- 
retic effect,  the  same  as  in  typhoid  fever. 

Frequently,  in  mild  cases,  sponging  the  surface  with 
tepid  water  is  not  only  grateful  to  the  patient,  but  it  has  a 
controlling  influence  over  the  fever.  If  vomiting  is  constant, 
severe,  and  exhausting,  hypodermics  of  morphine  will  be 
found  of  service. 

As  in  typhoid,  the  treatment  of  this  fever  is  ex^Dectaut, 
save  in  the  use  of  quinine. 


PERNICIOUS   MALARIAL   FEVER. 

I  now  pass  to  the  next  in  my  list  of  malarial  fevers,  which 
I  shall  describe  under  the  term  of  pernicious  fever.  This 
form  of  fever  has  received  other  names,  at  different  times 
and  in  different  localities.     It  has  been  called  congestive 


MOKl'.ID    AX  ATOMY.  149 

feter,  anient  fever,  tropical  t//p7wtdfcrer,  and  pernicious 
ferer. 

I  have  adopted  tli.-  latter  iiaiur.  for  it  seems  to  uic  to  be 
not  only  the  most  appi()i)riate,  but  the  one  wliich  at  the 
l)ivs('nt  time  is  most  f;:eneially  adopted.  It  is  true  tliat  in 
the  majority  of  cases  tliere  is  more  or  less  congestion  of  the 
internal  organs,  and  sometimes  the  patient  is  overwhelmed 
by  these  congestions,  but  in  a  large  number  of  cases  no  such 
congestions  exist,  and  under  such  circumstances  the  desig- 
nation pernicious  is  mostly  to  be  preferred. 

It  is  the  most  severe  and  dangerous  form  of  malarial 
fever.  It  may  be  intermittent  or  remittent  in  character, 
and  may  assume  any  of  the  types  of  periodical  fever,  but 
the  quotidian  and  tertian  types  are  the  most  common. 
Sometimes  its  pernicious  character  is  clearly  marked  at  the 
onset  of  the  fever,  during  the  first  paroxysm  ;  at  other 
times  it  comes  on  insidiously,  and  its  pernicious  character 
is  not  suspected  until  after  the  occurrence  of  two  or  three 
paroxysms. 

There  are  several  well-marked  and  distinct  varieties  of 
pernicious  fever — the  most  common  and  most  im])ortant  of 
which  are  the  comatose,  the  delirious,  the  alffid,  and  the 
f/as'fro-euteric.  Almost  every  locality  where  pernicious 
fever  prevails  gives  to  the  fever  some  distinctive  pecu- 
liarity. 

Pernicious  fever  not  infrequently  appears  as  an  e])idemic, 
although  sporadic  cases  are  met  with  in  those  regions  where 
simple  intermittent  and  remittent  fevers  prevail.  1  have 
seen  six  Avell-marked  cases  of  i)ernicious  fever  in  this  city 
during  the  past  year. 

MouRiD  Anatomy. — The  anatomical  lesions  of  pernicious 
fever  are  similar  in  kind  to  those  found  in  sim])le  intermit- 
tent and  remittent  fevers,  but  they  dilTer  very  much  in 
degree.  For  instance,  you  will  find  similar  blood-changes, 
the  most  striking  of  which  is  the  presence  of  free  pigment 
in  the  blood.  But  the  pigmentation  is  more  abundant,  and 
the  pigment  material  may  be  in  the  form  of  granules,  or  in 
the  form  of  plates,  or  it  may  even  have  a  cellular  outline. 
The  abundance  of  the  pigment,  and  the  extent  of  the  pig- 


150  PERNICIOUS   FEVER. 

mentation  will  vary  according  to  the  severity  of  the  fever 
But  in  all  cases  there  is  some  free  pigment  in  the  blood. 
This  pigment  is  not  often  present  in  the  blood  in  simple 
intermittent,  unless  the  fever  has  been  prolonged,  and  in 
simple  remittent  it  is  never  as  abundant  as  in  pernicious 
fever. 

The  other  changes  in  the  different  organs  and  tissues  of 
the  body  are  very  similar  in  character  to  those  to  which  I 
have  already  referred  in  connection  with  the  morbid  anat- 
omy of  intermittent  and  remittent  fever. 

As  the  varieties  in  tyjDe  of  this  fever  are  as  numerous  as 
the  localities  in  which  they  occur,  and  as  the  type  in  any 
locality  may  change  with  every  succeeding  year — that  is, 
the  type  of  one  year  may  be  very  unlike  that  of  the  preced- 
ing or  following  year — you  see  that  it  is  very  difficult  even 
to  classif}^  its  different  forms. 

The  slight  variations  which  are  met  with  in  the  patho- 
logical lesions  of  the  different  varieties,  are  still  more  diffi- 
cult of  description  and  classification.  For  instance,  there 
is  one  variety  which  is  characterized  by  a  tendency  to 
coma,  called  the  comatose  varieti/ ;  another  is  characterized 
by  a  tendency  to  a  peculiar  form  of  delirium,  termed  the 
delirious  variety;  still  another  which  is  characterized  by 
a  marble-like  coldness  of  the  surface,  called  the  algid 
variety ;  again,  we  have  one  which  is  characterized  by 
vomiting  and  purging,  or  choleraic  symptoms,  termed  the 
g astro-enteric  variety ;  then  one  in  which  there  is  acute 
jaundice,  termed  the  icteric  variety ;  then  one  in  which 
there  are  profuse  hemorrhages,  termed  the  liemorrhaglc 
variety,  and  still  another  in  which  there  is  profuse  diapho- 
resis, termed  the  colliquative  variety. 

These  are  the  more  common  varieties  of  pernicious  fever. 
There  are  still  others  of  such  rare  occurrence  that  it  is  hardly 
necessary  that  I  should  mention  them,  as  they  are  slight 
variations  due  to  local  causes.  ]N"one  of  these  are  distinct 
fevers,  but  different  types  of  the  same  fever. 

As  in  scarlatina,  measles,  and  small-pox,  we  have  differ- 
ent names  assigned  to  different  types  of  the  same  disease, 
so  all  these  forms  of  pernicious  fever  are  simplj'^  different 


MoKHID    AXATOMY.  IHl 

manifestations  of  one  and  thr  saiur  fever,  duo  to  cm'  and 
tlie  same  eause,  naint'ly,  malarial  ])oisoning. 

You  will  find  the  post-mortem  a|)i)earances  in  j).!  nifiouyi 
fever  varyinii;  with  the  intensity  of  the  malarial  infection, 
and  tlie  ])eculiar  atmospheric  conditions  under  which  the 
lever  is  developed. 

In  some  instances  there  will  be  evidences  of  intense 
eni;-orgement  of  the  blood-vessels  of  the  brain,  and  tlie  entire 
brain  sul)stance  will  be  more  or  less  thoroughly  stained 
with  ]iigment  material.  In  others,  minute  blood-extravasa- 
tions will  be  found  scattered  here  and  there  throughout  the 
substance  of  organs.  Small  blood-extravasations  into  the 
spinal  cord,  accompanied  by  more  or  less  pigmentation,  is 
very  apt  during  life  to  be  attended  by  tetanic  spasms.  In 
persons  dying  of  pernicious  fever  after  the  third  attack,  I 
have  found  all  the  organs  of  the  body  pigmented. 

Sometimes  you  will  find  intense  engoi-gement  of  the  liver, 
that  is,  the  most  marked  post-mortem  changes  will  be  found 
in  that  organ,  and  the  amount  of  pigmentation  present  will 
correspond  with  the  inti^nsity  of  the  congestion.  With 
intense  engorgement  of  the  organ  there  are  usually  blood- 
extravasations. 

Occasionally,  infarctions  occupy  the  spleen,  around  which 
there  will  be  a  mass  of  puljjy  mat(^rial.  The  spleen  is  more 
frequently  found  softened  in  this  form  of  malarial  fever 
than  in  those  forms  already  described.  Although  enlarged, 
it  is  usually  softened  and  of  a  darker  color  than  normal. 
It  is  sometimes  so  soft  that  it  closely  resembles  the  spleen 
of  typhoid  fever,  and  is  merely  a  pul])y  bloody  mass,  though 
in  size  it  is  larger  than  in  typhoid  fever.  If  not  softi-ned 
it  may  have  infarctions  scattered  tlirough  its  substance. 
Marked  pigmi'Utation  of  the  tissues  of  the])ody,  <-orresi)ond- 
ing  in  anu)unt  with  the  peculiar  symi)toms  present  during 
life,  a  tendency  to  enlargement  and  softening  of  the  spleen, 
enlargement  of  the  liver  with  deeper  pigmentation  than  is 
seen  in  any  other  organ  of  the  body,  are  among  the  more 
common  })athological  lesions  of  this  form  of  fever.  It  is 
unnecessary  to  d«'scribe  in  detail  that  enlargement  of  the 
ca])illaiy  vessels  which  occurs  as  a  necessary  result  of  this 


152  PEENICIOUS   FEVER. 

intense  engorgement.  Sometimes  tlie  kidneys  and  tlie  lungs 
are  the  seat  ol'  this  intense  hypersemia,  as  the  result  of  which 
the  functions  of  these  organs  are  more  or  less  extensively 
interfered  witli. 

Etiology. — The  exciting  and  predisposing  causes  of  per- 
nicious fever  differ  from  those  of  the  simpler  forms  of  mala- 
rial fever  only  in  degree,  not  in  kind,  but  a  higher  range  of 
temperature  is  requisite  for  the  development  of  pernicious 
fever.  It  prevails  only  in  those  localities  where  the  average 
range  of  temperature,  for  a  time,  reaches  65°  F. 

Sympto:hs. — Pernicious  fever  may  commence  abruptly, 
but  generally  the  premonitory  symptoms  which  mark  its 
development  do  not  differ  from  those  which  mark  the  de- 
velopment of  simple  intermittent  and  remittent  fever.  In 
most  varieties  the  attack  commences  with  a  chill,  which  is 
unusually  severe  and  prolonged.  In  many  cases  you  will 
have  a  distinct  malarial  paroxysm  of  either  the  intermit- 
tent or  remittent  type,  and  the  pernicious  character  of  the 
fever  is  engrafted  upon  it.  In  other  words,  you  may 
have  the  attack  commencing  with  a  distinct  intermittent 
fever  paroxysm  of  the  quotidian  type,  but  rarely  more 
than  two  of  these  intermittent  paroxysms  will  occur 
before  it  assumes  the  pernicious  type,  if  it  is  to  become  a 
pernicious  fever;  or  you  may  have  a  remittent  fever  with  a 
distinct  exacerbation  and  remission,  which  may  go  on  for 
four  or  five  days  before  its  pernicious  character  will  be 
developed. 

The  milder  form  either  gradually  passes  from  a  simple 
intermittent  into  a  pernicious  fever  by  a  progressive  increase 
in  the  severity  of  the  symptoms,  or  a  single  paroxysm  of 
not  unusual  severity  is  suddenly  followed  by  a  pernicious 
one ;  this  latter  seldom  proves  fatal,  unless  it  has  been 
repeated  for  the  second  or  third  time.  Again,  you  ma}^ 
have  a  distinct  chill  followed  b}^  a  condition  that  you  will 
at  once  recognize  as  one  of  the  varieties  of  pernicious  fever. 
The  ushering-in  sj^mptoms  will  always  vary  with  the  type 
of  disease  which  is  about  to  be  developed. 

I  sliall  not  attempt  to  describe  the  phenomena  that  attend 
all  these  different  varieties,  but  will  only  speak  of  those 


SYMPTOMS.  inn 

most  commonly  mot  with,  mid  (Ictnil  rlioir  ju-oiiiincut  ;iii<l 
leading  yjnijjtoms. 

Comatose  A'ariktv. — We  will  suppose  that  a  ]talirnt 
has  a  distinct  ])aroxysm  of  one  of  the  simpler  forms  of 
malarial  fever,  cither  intermittent  or  remittent,  with  no 
special  phenomena  attending  it,  excei)t  tiiat  he  has  had  a 
more  severe  headache  than  ordinarily  occurs  in  a  sim])l<' 
form  of  malarial  fin-er  ;  with  this  ])t'rhaps  there  has  Ixtu 
vertigo,  a  stammtn-ing  and  indistinctness  in  the  speech,  an 
inability  to  talk  with  freedom,  and  a  more  than  usual  trem- 
ulousness  during  the  hot  stage.  From  this  condition  he 
passes  as  usual  into  the  hot  stage  of  an  intermittent,  or 
rapidly  into  an  exacerbation  of  remittent,  then  into  a  state 
of  stupor  and  unconsciousness,  and  finally  lies  upon  his 
back,  with  a  liushetl  face,  congested  conjunctiva,  dilated 
pupils ;  slow,  deep,  stertorous  respiration,  and  perhaps  a 
very  slow  pulse,  or,  if  slow  at  first,  it  may  soon  become 
frequent.  The  axillary  temperature  ranges  from  lor)""  F. 
to  107°  F*.  The  patient  is  now  nearly  unconscious  ;  he  is 
a])parently  paralyzed  ;  the  urine  is  retained  in  the  bladder, 
and  the  bowels  move  involuntarily.  If  the  pulse  is  slow,  it 
is  full  and  hard.  The  respiration  becomes  more  and  more 
stertorous,  unconsciousness  becomes  more  and  more  com- 
plete, until  he  finally  dies  in  a  state  of  complete  coma. 
Usually,  however,  a  moisture  makes  its  appearance  within 
twelve  hours  from  the  commencement  of  the  first  parox- 
ysm, and  the  patient  awakes  to  consciousness  in  the  midst 
of  a  profuse  perspiration.  The  headache  and  giddiness 
liave  now  nearly  jiassed  off,  and  if  the  fever  which  ])rec('ded 
it  was  remittent,  there  may  be  a  well-marked  remission  ;  if  it 
was  an  intermittent,  there  may  be  a  distinct  intermission. 
With  the  next  remittent  exacerbation  or  the  liot  s(ag(^  of 
intermittent,  the  ])ain  in  the  head,  giddiness,  unconscious- 
ness, and  all  the  symptoms  alread}''  described  will  return 
more  intense  in  character  than  before,  with  the  coma  and 
stupor,  and  perha})S  with  the  second  attack  the  patient 
passes  into  a  fatal  coma.  These  are  the  leading  phenomena 
which  attend  the  most  common  form  of  ])ernicious  fevci-. 

In  this  variety  ])atients  sometimes  pass  into  a  condition 


154  PERNICIOUS   FEVER, 

of  apparent  death,  wliicli  may  last  for  hours.  Some  are 
perfectly  conscious,  seeing  and  hearing  everything  which 
occurs  around  them,  while  they  are  unable  to  move  or  utter 
a  sound  ;  others  pass  into  a  state  of  unconsciousness,  but 
the  respiratory  movements  and  the  heart's  action  are  not 
perceptible.  Even  though  the  strongest  counter-irritants 
be  applied  to  the  surface,  there  is  no  sign  of  life,  until,  at 
the  beginning  of  the  sweating  stage,  the  patient  comes  to 
himself. 

If  a  patient  survives  the  first  paroxysm  of  this  form  of 
pernicious  fever,  quite  probably  he  will  die  during  the 
second.  With  each  successive  paroxysm  the  prognosis 
becomes  more  and  more  unfavorable  ;  patients  sometimes 
lie  in  a  comatose  condition  for  days,  and  finally  die  appar- 
ently from  cerebral  comj)ression. 

Delirious  Variety. — In  this  variety  your  patient,  after 
passing  into  the  hot  stage  of  an  intermittent  or  into  the  ex- 
acerbation of  a  remittent,  becomes  delirious.  Mild  delirium 
is  not  uncommon  during  the  progress  of  an  intermittent 
or  a  remittent  fever,  but  the  delirium  now  referred  to  is  of  a 
more  active  character.  If  then  delirium  is  developed  during 
the  exacerbation  of  a  remittent  or  during  the  hot  stage  of  an 
intermittent,  which  has  been  preceded  by  severe  headache, 
dizziness,  ringing  in  the  ears,  and  great  restlessness,  you 
may  be  quite  certain  that  you  have  to  deal  with  a  case  of 
pernicious  remittent  or  of  pernicious  intermittent  fever, 
especially  if  pernicious  fever  is  prevailing  in  the  locality.  In 
this  variety  of  pernicious  fever  there  will  also  be  more  or 
less  headache  during  the  interval,  and  perhaps  other  pecu- 
liar cerebral  phenomena.  The  delirium  which  appears  is 
always  violent  in  character ;  perhaps  the  patient  will  require 
restraint;  he  may  be  disposed  to  jump  out  of  a  window,  or 
In  some  way  to  do  injury  to  himself  or  those  around  him. 

During  the  paroxysm  of  delirium  the  patient's  face  be 
comes  flushed,  his  eyes  brilliant,  the  conjunctiv?e  injected, 
the  pupils  dilated,  and  he  is  constantl}^  crying,  singing,  and 
trying  to  escape.  In  those  who  are  extremely  ansemic  the 
countenance  assumes  a  pale,  sunken  aspect.  The  pulse  is 
full  and  hard,  and  the  carotids  beat  violently,  the  tempera- 


SYMPTOMS.  l^.j 

ture  often  roaclK^s  107''  F.  or  108°  F.  Tlic  ]iatl(Mit  may  n;- 
maiii  ill  this  delirious  state  for  hours.  Somewhat  siiddfiily 
he  passes  froiii  it  into  a  condition  of  colhipse,  or  lie  giadii- 
ally  sinks  into  a  coma  from  wliicli  lie  never  awakens.  Diii- 
ing  the  whole  ])eriod  the  axillary  temix'iature  rarely  falls 
below  lO.')"  F.  In  favorable  cases  the  delirium  gradually 
becomes  milder,  a  pi'ofuse  perspiration  comes  on,  and  the 
patient  falls  into  a  ])rolonged  sleej),  from  which  he  awakes 
conscious,  though  weak  and  exhausted,  with  headache  and 
vertigo,  but  without  the  slightest  recollection  of  what  has 
passed.  These  attacks  of  delirium  may  be  repeated  three 
or  four  times  before  a  fatal  termination  is  reached,  but  so 
much  danger  attends  them,  that  a  second  attack  should 
never  be  allowed  to  occur  if  it  can  be  prevented. 

In  this  variety  of  pernicious  fever,  other  nervous  pheno- 
mena may  accompany  or  take  the  place  of  the  delirium,  such 
as  ei)ile])tiform  convulsions,  tetanic  spasms,  etc.  The  teta- 
nic spasms  sometimes  assume  the  phenomena  of  hydropho- 
bia. 

That  form  of  tetanus  which  occurs  in  various  nialai-ial 
districts,  whic^h  is  sometimes  called  sporadic  tetanus,  I  be- 
lieve will  be  found  to  be  of  this  type,  and  simply  a  form  of 
pernicious  fever. 

Gastuo-Entekic  ^^vuiety.— In  this  variety  the  patient, 
after  he  has  passed  into  the  hot  stage  of  an  intermittent  or 
the  exacerbation  of  a  remittent,  is  seized  with  almost  inces- 
sant vomiting  and  purging.  The  vomiting  and  jmrging  is 
of  a  peculiar  character,  altogether  nnlike  that  which  is 
sometimes  present  in  the  simpler  forms  of  malarial  fever. 
There  is  blood-stained  material,  both  in  the  matter  vomited 
and  in  that  discharged  from  the  ])owels.  In  some  instances, 
the  discharges  may  be  so  reddened  as  to  look  like  beef- 
brine  or  the  washings  of  raw  beef ;  sometimes  the  proi)or- 
tion  of  blood  is  so  great  as  to  cause  the  discharges  to  have 
the  appearance  of  clear  blood.  In  some  endemics  the  dis- 
charges assume  the  :i])pearance  of  rice-water,  having  no 
odor,  and  similar  in  appearance  to  those  in  Asiatic  chol- 
era. The  patient  has  no  abdominal  pain  or  tendeiin'ss,  but 
has  a  sense  of  weight  and  burning  in  the  stomach,  accom- 


156  PERNICIOUS   FEVER. 

panied  witli  cramp  in  the  calves  of  the  legs,  coldness  and 
blueness  of  the  surface,  with  a  small,  almost  imperceptible 
pulse,  sunken  eyes,  and  the  facies  of  cholera.  So  closely 
do  these  patients  resemble  in  appearance  those  with  Asiatic 
cholera,  that  this  disease  has  frequently  been  mistaken  for 
cholera.  During  the  attack  the  thirst  is  most  intense.  The 
respiration  is  peculiar  ;  it  consists  of  a  double  inspiration, 
followed  by  a  double  sighing  expiration.  The  restlessness 
is  very  great,  the  patient  is  constantly  tossing  from  one 
side  to  the  other ;  sometimes  he  suddenly,  an  hour  or  two 
before  death,  springs  up  and  walks  across  the  room.  The 
usual  length  of  the  fatal  paroxysm  is  from  three  to  six 
hours.  Patients  die  in  a  state  of  collapse  ;  after  the  vomit- 
ing and  diarrhoea  have  assumed  the  characteristic  appear- 
ances already  described  very  few  patients  recover.  As  death 
approaches,  the  pulse  becomes  more  and  more  frequent, 
feeble,  irregular,  and  fluttering  in  character.  The  respira- 
tion is  more  and  more  prolonged  and  sighing,  the  skin  cold 
and  shrivelled,  and  covered  with  a  cold,  clammy  perspiration. 
It  frequently  liappens  when  all  these  symptoms  are  present 
that  the  patient  cannot  be  convinced  that  he  is  seriously  ill, 
and  wishes  to  get  out  of  bed  and  go  out  of  doors. 

It  is  important  to  remember  that  these  three  varieties  of 
pernicious  fever,  which  I  have  just  briefly  described,  are 
not  always  distinct,  but  the  symptoms  of  one  may  be 
mingled  with  those  of  another  ;  such  mixed  cases  are  very 
difiicult  to  classify. 


LECTURE    XIV. 


PERNICIOUS     FEVER. 

Symptoms  {contmueSj.—Diferen fial  Dlagno.^ is.— Progno- 
sis.— Treatment. 

At  my  last  lecture  I  spoke  of  the  comatose,  delirious,  and 
the  gastro-enteric  variety  of  pernicious  fever.  I  now  in- 
vite your  attention  to  the  consideration  of  another  variety, 
which  bears  a  striking  resemblance  to  the  one  we  last  con- 
sidered.    It  is  termed  the  algid  variety  of  pernicious  fever. 

Algid  Variety. — This  variety  is  characterized  by  coldness 
of  the  surface  of  the  body,  while  the  rectal  temperature 
may  range  from  104'  F.  to  107'  F.  Tlie  attack  begins  witli 
a  ciiill  of  not  unusual  severity  or  durati(jn,  but  soon  after 
the  patient  enters  the  hot  stage  of  the  paroxysm  ;  oi\  dining 
the  exacerbation  of  a  remittent,  the  surface  of  the  body  be- 
gins to  grow  cold,  while  at  the  same  time  he  complains  of 
a  sensation  of  burning  and  intense  thirst.  A  cold  perspira- 
tion soon  covers  the  surface.  Tlie  pulse  becomes  slowei-  and 
slower,  falters,  and  disap])ears  at  the  wrist.  Alternati'ly 
the  extremities  and  face  become  cold ;  only  the  abdomen 
retains  its  normal  t<'niperatur('.  The  surface  has  a  cold, 
marble-like  feel,  but  the  temperature  in  the  axilla  never  or 
rarely  falls  below  the  normal  standard.  In  the  comatose 
and  delirious  varieties  the  t«'m])«'rature  rises  higher  than 
normal,  and  may  reach  100'  F.  or  107'  F.,  but  in  this  vari- 
ety it  sometimes  falls  two  or  three  degrees  lower  than  nor- 
mal. The  tongue  becomi'S  white,  moist,  and  cold;  the 
breath  is  cold,  and  the  voice  feeble  and  sunken.    The  action 


158  PERNICIOUS   FEVER. 

of  llie  heart  is  feeble,  often  perceptible  only  on  ansculta- 
tion.  The  mouth  is  clean,  and  the  jjatient  seems  to  himself 
to  be  in  a  comfortable  condition,  except  that  he  feels  ex- 
hausted. The  expression  of  countenance  is  that  of  death. 
In  its  ])rogress  this  variety  of  pernicious  fever  is  very  insid- 
ious. If  you  are  not  familiar  with  it  you  will  quite  proba- 
bly mistake  the  calm  which  follows  the  febrile  excitement 
for  relief,  perhaps  attribute  it  to  some  plan  of  treatment 
which  you  have  pursued,  or  to  some  remedial  agent  which 
you  have  employed.  If  a  patient  in  one  of  these  paroxysms 
is  to  pass  on  to  recovery,  the  pulse  gradually  returns  in  the 
wrist,  and  the  surface  regains  its  normal  feel  and  tempera- 
ture. As  the  warmth  returns  to  the  surface  the  patient 
passes  on  to  convalescence  in  the  same  manner  as  patients 
recover  from  a  comatose  or  delirious  paroxysm. 

An  algid  pernicious  paroxj^sm  is  rarely  preceded  by  a 
distinct  intermission,  and  it  rarely  has  any  appreciable  re- 
mission. Once  establislied,  it  marches  steadily  on  to  a 
fatal  issue,  unless  arrested  by  treatment. 

There  is  another  variety  which  you  will  occasionally  meet 
with,  in  which  a  profuse  perspiration,  called  a  '■^  coUiqitoime 
sweat,'^''  comes  on  at  the  end  of  the  fever  stage  and  continues 
through  the  succeeding  intermission,  accompanied  by  great 
prostration,  feeble  heart  action,  and  labored  respiration. 
Upon  the  second  or  third  return  of  this  sweat  the  patient 
sinks  and  dies  apparently  from  exhaustion. 

Again,  severe  hemorrhage  from  the  stomach,  bowels,  or 
kidneys  may  occur  during  the  sweating  stage  of  a  perni- 
cious paroxysm  and  endanger  the  life  of  the  patient  from 
sudden  syncope. 

A  mild  form  of  haematuria  sometimes  occurs  independent 
of  a  pernicious  paroxysm  in  chronic  malarial  poisoning. 

There  is  still  another  variety,  concerning  which  I  will  say 
a  few  words.  It  is  always  endemic,  confined  to  certain 
localities,  occurring  in  those  localities  when  any  form  of 
pernicious  fever  prevails.     It  is  called  the  icteric  variety. 

Icteric  Variety. — This  variety  begins  with  a  violent, 
long-continued  chill,  during  which  jaundice  shows  itself. 
The  Jaundice  gradually  deepens,  and  extends  over  the  whole 


DIFFEllKXTfAL    DI ACN'OSIS.  1.59 

body.  Intenso  nausoa  accoiniiaiiies  its  dt'vclopincnt,  with 
a  copious  voinitiuu;  of  h\\t\  and  a  bilious  diairlKpa.  Tiio 
patit'Ut  sufTois  with  a  luost  iutrnsc  headache,  ])ain  in  tiio 
region  of  tlie  sjibM-u  and  over  the  kidneys,  and  a  feeling  of 
numbness  in  the  liiiil)s.  The  pulse  is  small,  frequent,  and 
liard.  The  urine  is  deep-colored.  As  the  hot  stage  conies 
on  the  pulse  becomes  more  frequent  and  fuller,  the  respira- 
tion is  labored,  the  skin  ver}'  hot,  the  t(Mn])ei'ature  icaching 
10G°  F.  or  107'"  F.,  and  the  thirst  is  most  intense.  This  stage 
lasts  three  or  four  hours,  and  often  terminates  in  deatli.  Jf 
the  patient  jxisses  into  the  sweating  stage,  recovery  usiuilly 
takes  place.  During  tlie  intermission  the  mind  is  clear,  but 
the  jaundice  continues.  Unless  the  disease  is  controlled  by 
treatment,  each  succeeding  paroxysm  becomes  more  and 
more  sev-ere.  This  variety  is  incorrectly  called  pernicious 
bilious  remittent  fever. 

If  the  attack  is  mild,  there  is  only  a  slight  staining  of  the 
skin,  but  in  that  form  in  wliich  there  is  an  apparent  arrest 
of  the  functions  of  the  liver,  the  patient  may  die  deeply 
jaundiced,  within  two  or  three  days  after  the  first  discolor- 
ation of  the  skin  has  appeared.  There  is  a  mild  form  of 
so-called  bilious  remittent  fever,  to  which  I  have  already 
referred,  in  which  the  febrile  movement  is  constant  ;  this  is 
very  different  from  that  form  to  which  I  now  allude,  and 
is  better  classed  under  the  head  of  simple  remittent. 

These  different  varieties  of  pernicious  fever,  of  which  I 
have  made  mention,  are  almost  the  only  ones  ordinarily 
met  with  in  practice.  It  seems  to  me  that  very  propi^rly 
they  may  all  be  considered  under  the  general  head  of  perni- 
cious fever. 

Remember  that  all  these  different  varieties  depend  on 
the  same  blood-poisoning,  differing  in  its  manifestations 
according  to  the  intensity  of  the  poison  and  the  predispos- 
ing atmospheric  or  septic  conditions  which  may  exist  in 
the  localities  where  they  are  develo])ed. 

Diffp:kextial  Diaoxosis. — The  diagnosis  of  pernicious 
fever  is  sometim<'S  very  difhcult.  In  determining  whether  a 
given  case  is.  or  is  not,  one  of  pernicious  fever,  the  first 
in(piiry  will  l)e  in  regard  to  the  charactr-r  of  the  ])revailing 


160  PERNICIOUS   FEVER. 

fever.  If  pernicious  fever  is  prevailing  in  tlie  locality,  doubt- 
less your  diagnosis  will  be  easily  made  ;  if,  however,  the  first 
case  in  the  locality  falls  under  your  observation,  probably, 
you  will  find  great  difficulty  in  making  a  diagnosis,  and 
this  difficulty,  to  a  certain  extent,  will  vary  with  the  type 
of  the  fever.  If,  for  example,  your  case  belongs  to  that 
class  in  which  there  is  a  tendency  to  comas,  delirium,  etc., 
you  may  confound  it  with  some  form  of  cerebral  disease. 
This  form  of  pernicious  fever  has  been  mistaken  for  cere- 
hral  apojylexy,  Tneningltls,  and  acute  urcemia.  As  a  rule, 
it  is  not  difficult  to  draw  the  line  between  apoplexy  and 
pernicious  fever  of  the  comatose  or  delirious  variety. 

The  constant  and  prominent  symptom  of  apoplexy  is 
hemiplegia,  which  is  of  rare  occurrence  in  pernicious  fever. 
It  may  occur,  but  if  it  does,  it  is  developed  slowly.  jSTeither 
coma  nor  hemiplegia  is  ever  reached  suddenly  in  pernicious 
fever.  There  is  a  rise  in  temperature,  raj^id  pulse,  and  all 
the  phenomena  of  intense  febrile  excitement  are  present 
before  the  occurrence  of  either.  On  the  other  hand,  in 
apoplexy  the  hemiiDlegia  is  of  sudden  development,  attend- 
ed by  a  slow  pulse,  irregular,  contracted  pupils  ;  or,  per- 
haps, one  pupil  is  dilated  and  the  other  contracted,  and  its 
occurrence  is  preceded  by  a  sudden  loss  of  consciousness, 
and  not  attended  or  preceded  by  high  febrile  excitement. 
These  marked  differences  between  the  two  diseases  will 
lead  3^ou  to  a  correct  diagnosis. 

As  regards  mistaking  pernicious  fever  for  meningitis,  it 
would  seem  hardly  possible  for  one  familiar  with  both 
diseases  to  make  such  a  mistake  in  diagnosis. 

Though  in  both  diseases  the  patient  reaches  a  condition 
of  coma,  in  meningitis  days  elapse  before  the  coma  is 
reached,  and  during  those  daj^s  there  has  been  pain  in  the 
head,  photophobia,  delirium  extending  over  a  considerable 
period  of  time,  and  then  the  coma  ;  whereas,  in  pernicious 
fever,  within  twelve  hours  the  patient  reaches  his  condition 
of  coma.  Besides,  in  pernicious  fever  there  will  be  a  his- 
tory, not  only  of  the  prevailing  type  of  malarial  disease, 
which  will  indicate  its  character,  but  there  will  precede  the 
attack  of  coma  or  delirium  a  distinct  malarial  paroxysm— 


DIFFEHENTIAL    DIACXOSIS.  101 

perhaps  two  of  tlh'sc  ]viroxysms ;  tlion  tlie  patient  will 
pass  rai>iclly  into  a  state  of  coma.  In  these  two  diseases 
the  condition  of  the  pupil  varies.  In  meningitis,  wlien  the 
patient  reaches  complete  coma,  the  ]nipil  will  be  dilated, 
while  in  the  comatose  variety  of  ])ernicious  fever  the  pupil 
may  be  contracted,  dilated,  or  normal. 

The  gastro-enteric  and  cold  or  algid  variety  of  pernicious 
fever  closely  resembles  cholera.  It  nitiy  be  distinguished 
from  it  by  the  chai-acter  of  the  primary  discharges.  You 
may  reach  a  time  in  pernicious  fever  when  the  discharges 
will  verj'  closely  resemble  those  of  cholera  ;  but  they  have 
been  preceded  by  one  or  two  blood}*  discharges.  Then  in 
cholera  you  will  have  albumen  in  the  urine,  the  occurrence 
of  which  is  comparatively  rare  in  pernicious  fever.  Then  in 
cholera  there  are  the  peculiar  surroundings  of  the  patient, 
the  prevalence  of  cholera  in  the  locality,  etc.  Yet,  in  a  recent 
endemic  of  choleraic-]iernicious  fever  which  prevailed  along 
the  banks  of  the  lower  Mississippi,  many  prominent  ])hy- 
sicians  maintained  that  it  was  an  epidemic  of  Asiatic 
cholera.  When  the  endemic  is  at  its  height  it  is  almost  im- 
possible to  make  a  differential  diagnosis  between  the  two 
diseases  from  the  clinical  history  of  the  cases  ;  but,  when 
you  take  the  early  history  of  the  endemic,  at  which  time 
the  cases  at  theii"  commencement  were  marked  by  distinct 
intermittent  or  remittent  paroxysms,  then  the  true  charac- 
ter of  the  disease  is  very  readily  determined.  If  in  any 
given  case  there  is  still  a  question  whether  it  is  or  is  not 
one  of  pernicious  fever,  this  can  be  determined  with  posi- 
tiveness  by  placing  some  of  the  patient's  blood  under  the 
microscope,  when,  if  the  case  be  one  of  pernicious  fever, 
the  blood  will  be  found  to  contain  pigment. 

The  icteric  variety  of  pernicious  fever,  which  often,  in 
many  of  its  ]>hen()meiia,  so  closely  resembles  yellow  fever, 
may  be  distinguished  from  it  not  oidy  l)y  the  history  of  its 
development,  but  by  tlie  fact  that  when  it  ])revails  as  an 
endemic,  those  are  seized  with  the  f»n'er  who  have  been 
longest  under  the  iulhienceof  malarial  poison,  when-as  new- 
comers are  not  usually  attacked;  in  yellow  fever  districts 
new-comers  are  almost  certain  to  contract  the  disease. 
11 


162  PERNICIOUS   FEVEE. 

Then  the  jaundice  of  yellow  fever  appears  late  in  the  dis- 
ease, while  tlie  jaundice  of  this  form  of  pernicious  fever 
comes  on  early,  even  before  the  chill  passes  away.  Again, 
bloody  urine  is  frequently  present  in  this  type  of  pernicious 
fever,  while  in  yellow  fever  h^ematuria  rarely  occurs  with- 
out the  accompanying  evidences  of  nephritic  inflammation. 

It  is  hardly  necessary  for  me,  under  the  head  of  differen- 
tial diagnosis,  to  speak  of  all  the  different  varieties  of  per- 
nicious fever,  for  there  is  one  thing — the  presence  of  free 
pigment  in  the  blood— which  settles  the  question  of  diag- 
nosis in  difficult  cases ;  this  is  present  in  nearly  every 
severe  case  in  any  form  of  pernicious  fever. 

Whenever  any  of  these  types  of  pernicious  fever  prevail 
in  the  region  where  you  are  located,  you  will  soon  become 
familiar  with  their  peculiar  phenomena,  and  thus  be  able 
to  make  an  early  diagnosis.  You  must  bear  in  mind  that, 
though  you  have  become  familiar  with  one  variety  of  this 
fever,  you  are  by  no  means  prepared  to  make  an  early 
diagnosis  of  any  other  variety,  for  the  algid  and  comatose 
varieties  differ  as  widely  in  the  phenomena  which  attend 
their  development  as  though  they  were  distinct  diseases 
and  did  not  depend  uj)on  the  same  poison. 

Progistosis. — In  all  varieties  of  pernicious  fever  the  prog- 
nosis is  unfavorable.  Unless  you  are  able  to  control  the 
disease  before  the  occurrence  of  the  second  paroxysm,  usu- 
ally the  case  will  terminate  fatally.  In  all  cases  the  prog- 
nosis will  depend,  to  a  great  degree,  upon  the  character 
of  the  prevailing  endemic  or  epidemic,  as  also  upon  the 
stage  of  the  epidemic,  for  the  ratio  of  mortality  is  always 
greater  during  the  early  period  of  an  epidemic  than  during 
its  decline.  During  the  latter  part  of  an  epidemic  you 
may  tliink  you  are  managing  your  cases  better  because 
fewer  patients  die,  while  the  good  results  are  due  to  the 
fact  that  the  epidemic  is  on  the  decline.  All  observers 
agree  that  the  prognosis  is  better  in  every  variety  of  per- 
nicious fever  if  there  are  distinct  intermissions,  however 
short  may  be  their  duration.  If  the  paroxysm  does  not 
last  more  than  twelve  hours,  and  terminates  in  a  distinct 
remission,  the  prognosis  is  far  better  than  when  one  parox- 


PROGNOSIS.  1 0:^ 

Ysni  follows  aiiotlirr  wiilioiit  :iiiy  dislinct  remission.  If 
tlu*  ])aroxysius  air  incrrasirii;'  in  st'V<'rify  and  diirafioii,  iIk- 
])atK'Ut  is  liable  to  die  in  tlif  third  or  fourth  itaroxysni. 

Unquestionably  the  most  favorable  cases  are  those  of  the 
tertian  tyjM'.  Those  varieties  in  which  the  cases  most  fre- 
quently terminate  fatall}'  are  the  gastro-enteric  and  the 
algid  ;  those  in  which  the  cases  are  most  likel}^  to  recover 
are  the  comatose  and  delirious. 

In  every  case  the  prognosis  is  very  much  inlluenccd  by 
the  age  and  condition  of  the  patient,  and  by  the  presence  or 
absence  of  complications.  The  mortality  is  greatest  among 
the  very  young  and  very  old,  and  among  the  intemperate. 

Patients  with  pernicious  fever  may  die  suddenly  during 
a  paroxvsm,  or  the  paroxysms  may  be  prolonged  and  run 
into  each  other,  and  the  patient  ma}^  finally  pass  into  a 
typhoid  or  collapsed  condition. 

In  every  variety  of  pernicious  fever  you  may  be  aided  in 
making  a  prognosis  by  remembering  what  I  am  about  to 
state. 

If  the  second  or  third  paroxysm  is  not  attended  by  signs 
of  intense  visceral  congestion,  if  it  declines  with  profuse 
warm  sweats,  if  it  has  been  preceded  by  distinct  intervals, 
if  the  urine  is  free  and  the  appetite  early  returns,  you  may 
safel}'  prognosticate  a  speed}'  recovery.  On  the  other  hand, 
if  the  second  or  third  ])aroxysm  is  protracted  and  accompa- 
nied by  great  anxiety  and  restlessness,  with  active  delirium 
and  a  tendency  to  coma,  with  coldness  of  the  surface  ;  if 
there  is  intense  })ain  in  the  epigastrium,  with  tingling  of  the 
surface,  and  scanty  and  high-colored  mine  ;  if  there  is  pro- 
fuse vomiting  and  ])urging,  bleeding  at  the  nose  and  cold, 
colliquative  sweats;  if  the  i)ulse  becomes  small  and  feeble, 
or  the  radial  pulse  is  imperceptible,  the  danger  is  very  great, 
and  a  fatal  issue  is  almost  certain,  either  imnied-iately  or 
in  the  fourth  or  fifth  paroxysm.  Sometimes  severe  and 
fatal  djsentery  comes  on  at  the  end  of  a  paroxysm  ;  at 
other  times,  as  the  ])aroxvsm  subsides,  the  fever  assumes  a 
tj'phoid  tyi)e,  and,  after  a  ])eriod  of  continued  fever  ranging 
from  ten  to  twelve  days,  it  terminates  fatally. 

Tke.vtment.— The  expectant  plan  of  treatment,  which  has 


164  PEENICIOUS   FEVER. 

been  proposed  for  the  management  of  some  of  the  forms  of 
fever  wiiicli  have  engaged  our  attention,  cannot  be  practised 
in  the  treatment  of  pernicious  fevers.  The  ahirming  symp- 
toms crowd  upon  one  another  with  great  rapidity,  and  it  is 
only  by  prompt  and  vigorous  measures  that  in  the  severe 
forms  of  tlie  disease  you  will  be  able  to  rescue  your  patient 
from  impending  death.  The  issue  of  life  or  death  often 
hangs  upon  a  single  lionr. 

Some  have  proposed,  before  administering  the  only  spe- 
cific which  we  possess  capable  of  controlling  this  disease, 
to  produce  free  purgation  by  the  administration  of  cathar- 
tics ;  others  to  bleed  and  freely  vomit  the  patients.  If  the 
case  is  one  of  the  gastro-enteric  variety,  emetics  and  purga- 
tives are  certainly  very  plainly  contra-indicated.  It  is  now 
a  well  established  fact  that  in  all  varieties  of  pernicious 
fever  patients  do  not  bear  depletion.  In  India,  where  the 
most  severe  forms  of  pernicious  fever  prevail,  the  English 
surgeons  are  very  positive  in  their  testimony  upon  this  point. 
All  forms  of  depletion  have  been  abandoned  in  the  India 
service. 

Although  stimulating  enemas  and  friction  to  the  surface 
may  act  as  aids  in  the  management  of  the  algid  and  deliri- 
ous varieties,  they  must  not  be  relied  upon  for  any  control- 
ling influence  which  they  may  have  over  the  disease. 

Those  who  have  had  the  most  extended  opportunities  for 
testing  the  different  remedies  and  plans  of  treatment  which 
have  been  em^^loyed  in  the  management  of  this  fever,  are 
united  in  the  opinion  that  quinine  and  opium  are  the  only 
agents  which  can  be  relied  upon  for  controlling  every 
variety. 

In  the  treatment  of  this  fever  my  own  experience  is  not 
extended ;  consequently,  I  am  compelled  to  give  you  the 
teachings  of  those  who  have  written  upon  this  fever. 

So  far  as  I  have  been  able  to  arrive  at  conclusions  from 
my  readings,  as  well  as  from  my  limited  experience  in  the 
treatment  of  this  disease,  I  am  convinced  that  in  the  major- 
ity of  cases,  b}^  the  use  of  opium  and  quinine  hjq^oderini- 
cally,  we  may  hope  to  control  it,  and  thus  save  the  life  of 
our  patient. 


TREATMENT.  165 

Til  fact,  (lie  liyjxxlcrinir  use  of  tlicsc  dru^s  lias  iiiaiiuii- 
latftl  u  iK'w  t'la  ill  its  (icatiiiciit,  I'ur  in  a  lar^r  ])i())>(»rli()ii 
of  the  severer  forms  it  is  iiii])()ssible  to  ^ft  tli<'  full  ell'cct  of 
eillicrof  these  iciiicdirs  hy  iIk'  oidiiiaiy  iu«l  IkhIs  (»r  fln-ii' 
adiiiiiiistnition,  (lie  usual  avniues  for  tin -jr  in  hod  net  Idh  into 
the  sj'stt'iu  Ix'ini;;  closed. 

The  soliitiiiii  of  (luinine,  coimiioiily  fiuitioyrd  hy  the 
Enu-lisli  surucoiis  for  this  i)iir])os(>,  is  made  by  addiiiii;  one 
hundred  and  lifty  grains  of  (quinine  and  lil'ty  dioijs  of  di- 
hite  li\-droi-liI()iic  acid  to  four  ounces  of  watt-r,  and  then 
eva])oratin^i^  the  solution  to  two  ounces.  Of  this,  thirty 
drops  may  lie  administered  at  each  injection.  Some  add 
carbolic  acid  to  a  solution  of  (|uiniii.'  in  dihilr  suljihuric 
acid  ;  the  carbolic  acid  is  addi-tl  to  j)reveiit  abscess  at  the 
point  where  the  injection  is  introduced. 

The  formula  for  this  solution  is  as  follows  : 

^.  Quinia  di-ul])liatis (rrs.  1. 

Acid  sulphurici iiL.  v. 

Acid  cai'bolici iil.  ij. 

Aqua3  destillat 3  i. 

M. 

Thirty  minims  is  the  qnantity  nsually  administered  at 
each  hypodermic  injection  ;  it  represents  between  three  and 
four  grains  of  quinine.    T  have  recently  used  the  following: 

IJ.  (^hiinia  sulpli 3  i, 

Hydrolnomic  acid 3  ij. 

Aquae  destillat 3  \  i. 

M. 

Thirty  minims  contain  four  grains  of  quinine. 

Whatever  solution  you  may  use,  administer  from  live  to 
seven  grains  of  ([uiniiie  every  hour  until  the  ])aroxysm  has 
passed,  then  continue  its  use  in  three  grain  doses  every 
four  hours. 

With  the  quinine  of  the  first  liyjiodcrniic  iiijecti(»n  admin- 
ister one-fourth  of  agrain  of  mori»liia.  The  inor})liine  slmnld 
be  administered  with  each  dose  of  quinim*  until  the  j.atient 


166  PERNICIOUS   FEVER. 

is  brought  fully  under  its  influence,  witliout  regard  to  tlie 
stage  of  the  paroxysm. 

During  the  past  few  years  a  remedy  known  as  "  War- 
burg's Tincture"  has  been  quite  extensively  employed  in 
the  treatment  of  pernicious  fever  by  the  India  sui-geons. 
AVhen  this  remedy  was  first  employed,  its  ingredients  were 
unknown,  and  on  this  account  it  was  not  generally  made 
use  of  by  the  profession.  All  those  who  used  it  claimed 
that  it  more  successfully  controlled  the  fever  than  opium 
and  quinine,  or  any  other  remedy  that  had  hitherto  been 
employed.  The  results  claimed  for  it  were  really  astonish- 
ing. 

Recently,  the  formula  for  making  this  tincture  has  been 
published  in  the  London  Lancet.  I  will  give  it  as  pub- 
lished. 

Formula. 

Warburg' s  Tincture. 

1^.  Aloes  (Socotr.)  librom, 
Rad.  rhei  (East  India), 
Sem.  Angelica, 

Confect.  Damocratis,  ana  uncias  quatuor, 
Had.  Helenis  (s.  Enulse), 
Croci  sativi, 
Sem.  Foeniculi, 

Cret.  prseparat,  ana  unc.  duas. 
Had.  Gentianse, 
Had.  Zedoariee, 
Pip.  Cubeb., 
Myrrh.  Elect., 
Camphorse, 
Bolete  laricis,  ana  unciam. 

T/ie  above  ingredients  to  be  digested  with  500  ounces  of 
'proof  spirit  in  a  loater-batli  for  twelve  liours ;  then  ex- 
pressed and  ten  ounces  of  disulpliate  of  quinia  added,  tlie 
mixture  to  be  replaced  in  the  water-bath  until  all  the  qui- 
nia be  dissolved.  The  liquor .^  when  cool.,  is  to  be  filtered^ 
and  is  then  fit  for  use. 


TREATMENT.  1 '"»7 

Tr  will  1).'  s(vn  that  eacli  luilf-oiinci'  of  lli»'  tincture  con- 
tains seven  and  a  half  ,i;rains  of  »piininf.  It  is  reconi- 
menth'tl  to  i;iv(;  half  an  onner  of  this  tinctnrc  at  the  onset 
of  the  paroxysm;  if  this  does  not  control  it,  the  same 
quantity  must  bf  n'lx'aicd  in  four  liours.  If  it  cannot  be 
retained  by  the  stomach,  it  may  bf  administered  by  the 
rectum,  in  oiiiii-e  (loses  every  hour.  It  is  claimed  that  the 
tincture  is  retained  by  the  stomach  when  all  other  remedies 
are  rejected.  Prof.  Machnui  says  that  h.3  has  seen  the  most 
hopeless  cases— those  manifesting  a  degree  of  severity 
whicli  seemed  to  i)reclude  the  possibility  of  recovery— com- 
mence to  convalesce  as  soon  as  the  i)atient  was  brought 
uiiil<'r  the  inlluence  of  this  remedy.  I  will  (|uote  Prof. 
Maclean's  rules  for  its  administration  : 

"The  tincture  is  administered  in  the  following  manner: 
One-half  ounce  (half  of  a  bottle)  is  given  alone,  without 
dilution,  after  tlie  bowels  hav(-  been  evacuated  by  any  con- 
venient purgative,  all  diink  being  withheld  ;  in  three  hours 
the  other  half  of  the  bottle  is  administered  in  the  same 
way.  Soon  afterwards,  particularly  in  hot  climates,  pro- 
fuse, but  seldom  exhausting,  perspiration  is  produced  ; 
this  has  a  strong  aromatic  odor,  which  I  have  often  detected 
about  the  patient  and  his  room  on  the  following  day. 
"With  this  there  is  a  rapid  decline  of  temperature,  imme- 
diate abatement  of  frontal  headache — in  a  word,  complete 
defervescence,  and  it  seldom  happens  that  a  second  bottle 
is  required.  If  so,  the  dose  may  be  repeated  as  above.  In 
very  adynamic  cases,  if  the  sweating  threatens  to  prove 
exhausting,  nourishment  in  the  shape  of  beef-tea,  with  tlie 
addition  of  Liebig's  extract  and  some  wine  or  brandy  of 
good  quality,  may  be  required." 

No  special  rules  can  be  laid  down  in  regard  to  tlie  admin- 
istration of  stimulants  in  pernicious  fever  ;  the  condition  of 
the  patient  must  be  your  guide.  They  are  simply  means 
used  to  aid  in  carrying  a  patient  over  a  dangerous  period. 
Their  continued  use  in  large  quantities  is  objected  to  hy 
those  who  have  had  the  most  extended  experience  in  tin? 
management  of  this  fever. 

I  will  repeat  in  as  few  words  as  possible  the  imixjrtant 


168  PERNICIOUS   FEVER. 

things  to  be  remembered  iu  the  treatment  of  pernicious 
fever.  Do  not  Avait  for  the  action  of  a  calomel  purge.  Do 
not  resort  to  any  depleting  measures  ;  patients  with  this 
fever  cannot  bear  depletion.  However  mild  the  paroxysm 
ma}^  be,  no  time  should  be  lost ;  bring  the  patient  as  rapid- 
ly as  possible  under  the  influence  of  quinine  and  opium, 
or,  if  "Warburg's  Tincture"  is  used,  administer  it  in  full 
doses  as  early  as  possible,  and  continue  its  administration 
until  convalescence  is  fully  established. 


LECTURE    XV. 


DENGUE  FEVER. 


Morbid     Anatomy. — Ettologj/. — Symjytoins. — Differ  eutial 
Diagnosis. — Treatment. — Chron ic  JIalarial  Infection. 

Before  leaving  the  class  of  fevers  which  has  just  been 
engaging  our  attention,  I  wish  to  say  a  few  words  concern- 
ing a  fever  which,  although  it  may  not  properly  be  included 
in  the  list  of  malarial  fevers,  yet  it  seems  to  me  that  it  can 
be  best  considered  in  this  connection.  It  has  received  the 
names,  dengue,  break-bone,  and  dandy  fever.  It  is  neither 
an  intermittent  nor  a  reniittrnt  fever  ;  nor  is  it  a  pernicious 
fever.  It  is  an  acute  disease  which  appears  as  an  e])idemic 
in  hot  climates.  It  is  characterized  by  a  febrile  excitement 
remitting  in  its  character,  and  is  accompanied  by  more  or 
less  intense  arthritic  pains,  attended  by  the  development  of 
a  papillary  eruption  resembling  that  of  measles. 

M(»Knir)  Anatomy. — The  moibid  anatomy  of  this  variety 
of  fever  does  not  diifer  essentially  from  that  of  the  severer 
types  of  malarial  fever,  except  tliat  a  ciilancous  eru]»tion 
commences  on  the  ])abus  of  tln^  hands  and  extends  rapidly 
over  the  entue  body.  In  most  cases,  arthritic  changes  of  a 
rheumatic  character  are  present ;  usually  the  external  lym- 
phatic glands  are  somewhat  enlarged. 

This  disease  seems  to  be  an  exantiu-matous  mahirial 
fever,  with  a  rheumatic  or  neuralgic  element. 

Etiology. — l)<'iigue  or  break-bone  fever  may  jirevail  epi- 
demicallv  in  well   nuirked  malarial  districts,  or  it  may  be 


170  DENGUE   FEVER. 

met  with  as  a  sporadic  disease.  Its  infection  has  been 
carried  in  clothing  from  one  seaport  to  another.  Some 
claim  that  tlie  disease  depends  upon  a  specific  contagion ; 
but  its  contagious  character  has  not  been  established. 

The  intensity  of  the  malarial  poison  unquestionably  has 
some  iiitluence  in  increasing  or  lessening  the  severity  of  tliis 
fever.  In  districts  slightly  malarial  usually  its  type  is  mild  ; 
but  in  districts  strongly  malarial  its  type  is  severe.  It 
attacks  all  classes  and  all  ages,  rich  and  poor,  black  and 
white,  the  very  young  and  the  very  old.  Occasionally  it 
has  occurred  as  the  i3recursor  of  yellow  fever.  In  1827  a 
very  extended  epidemic  of  this  fever  prevailed  in  the  West 
Indies  ;  during  the  prevalence  of  this  epidemic,  the  specific 
poison  of  the  disease  was  transported  in  clothing  and  mer- 
chandise to  many  neighboring  seaports. 

Symptoms. — Tiie  period  of  incubation  is  estimated  from 
three  to  five  days.  The  initiatory  sj'mptoms  are  very  sud- 
den in  their  manifestation,  and  the  development  of  the  fever 
is  very  rapid.  In  the  majorit}^  of  cases,  the  earliest  symp- 
toms are  headache,  photophobia,  great  restlessness,  chilli- 
ness alternating  with  flashes  of  heat,  and  pain  in  the  back, 
limbs,  and  joints  ;  the  small  Joints  SAvell,  and  there  is  sore- 
ness and  stiffness  of  the  muscles.  The  skin  becomes  hot 
and  dry,  and  in  some  instances  the  temperature  reaches 
107°  F.  The  pulse  is  rapid,  ranging  from  120  to  140  beats 
per  minute.  The  face  is  flushed  and  the  ejes  red  and 
watery.  After  the  fever  has  continued  about  twelve  hours, 
the  pains  in  the  joints  become  intense,  the  pain  in  the  back 
shoots  down  the  sciatic  nerve,  and  now  nausea,  vomiting, 
and  pain  in  the  epigastrium  are  usually  the  prominent 
symptoms. 

At  this  stage  of  the  fever  the  Ijmiphatic  glands  become 
involved  ;  the  inguinal  glands  are  first  affected,  then  those 
in  the  axilla  and  neck  ;  they  increase  very  rapidly  in  size, 
and  become  exceedingly  tender.  The  testicles  enlarge,  or 
rather  the  epididymis,  and  the  swelling  continues  until  the 
subsidence  of  the  other  symptoms.  The  active  febrile 
excitement  continues  from  twelve  hours  to  three  or  four 
days,  when  it  subsides,  leaving  the  patient  in  an  exceed- 


SYMPTOMS. 


ingly  feeble  and  prostrate  condition.  Somctiines  tlie  fev(n- 
abates  suddenly,  with  the  occurrence  of  critical  synii)ton»s 
as  in  re]apsin«j;  fever,  such  as  profuse  sweats,  diarrluea,  or 
epistaxis.  Then  the  patient  is  in  a  ])assive  condition  for 
two  or  three  days,  and  ])asses  into  the  ])eriod  of  remission. 
The  jiains  now  become  less,  the  glanduhir  swellings  diminish, 
there  is  less  of  febrile  excitement,  but  it  does  not  entirely 
subside.  After  two  or  three  days  a  second  paroxysm  occurs, 
and  the  fever  returns.  About  the  same  time  intervenes 
between  the  first  and  second  paroxysm  as  occurs  between 
the  iirst  and  second  inuoxysm  of  relai)sing  fever.  When 
the  fever  returns  it  is  more  intense,  the  pain  in  the  joints  is 
more  severe,  and  tinally,  when  the  fever  has  reached  its 
height  and  the  i>ain  is  most  intense,  usually  on  the  fifth  or 
sixth  day,  an  eruption  makes  its  appearance.  It  first  ap- 
pears upon  the  italms  of  the  hands,  then  u})<)n  the  neck; 
soon  it  extends  downward  and  is  seen  upon  the  chest,  and 
tinally  spreads  over  the  entire  body.  Usually  it  is  pai)il- 
lary  in  character  and  very  closely  resembles  the  eru])tion 
of  scarlatina.  In  most  cases,  as  soon  as  the  erujjtion  is 
developed,  the  fel)rile  symptoms  subside  and  the  i)titieut 
goes  on  to  convalescence. 

From  the  intense  arthritic  pains  accom])aiiying  the  papil- 
lary eruption,  and  from  the  glandular  swellings,  you  will  be 
able  to  recognize  this  peculiar  type  of  fever.  As  the  second 
paroxysm  of  fever  subsides,  the  ])atient  is  left  with  stiffness 
and  soreness  of  the  joints,  which  sometimes  does  not  pass 
away  for  weeks.  Occasionally  the  disease  assumes  a  ty- 
phoid type,  the  tongue  becomes  coated  with  a  dark  brown 
coating,  the  gums  become  red  and  spongy,  the  i)ulse  is  slow 
and  feeble,  and  the  surface  is  covered  with  a  cold  sweat. 
As  soon  as  the  eruption  appears,  the  patient  is  generally 
free  from  fever,  and  passes  on  to  a  rapid  and  C()mi)l»'te  con- 
valescence. 

In  vtny  severe  cases  the  ])ain  in  the  testicles  will  con- 
tinue after  the  subsidence  of  the  fever,  and  a  serous  effusion 
will  take  place  into  the  tunica  vaginalis.  The  joints  will 
remain  ])ainful  and  flabby.  Th^re  will  be  extreme  nervous- 
ness and  an.xiety.     The  heart's  action  will  be  intermittent, 


172  DENGUE  FEVER. 

and  tlie  lympliatic  glands,  which  have  been  enlarged,  form 
indurated  tumors  ;  they  very  rarely  suppurate.  The  dura- 
tion of  this  fever  varies  with  the  period  of  remission.  Its 
average  duration  is  about  eight  days. 

In  those  epidemics  where  there  is  an  absence  of  articular 
pains,  the  mucous  membrane  of  the  mouth  and  throat  be- 
comes involved. 

The  course  of  the  disease  may  be  divided  into  periods. 
First,  that  of  febrile  exacerbation,  lasting  two  or  three  days, 
then  an  intermission  of  two  or  three  days,  then  a  second 
febrile  exacerbation  which  lasts  two  or  three  days,  then 
convalescence  begins. 

Differential  Diagnosis. — This  fever  may  be  confound- 
ed with  rheumatism,  or  with  remittent  fever.  In  some  of 
its  phenomena  it  closely  resembles  relapsing  fever. 

It  may  be  distinguished  from  remittent  fever  by  the  per- 
sistency of  the  rheumatic  and  neuralgic  pains,  by  the  cuta- 
neous eruption,  and  by  the  length  of  the  remission. 

It  may  be  distinguished  from  rheumatism,  as  it  prevails 
epidemically,  and  a  period  of  febrile  excitement  precedes 
the  arthritic  phenomena.  It  may  be  distinguished  from 
relapsing  fever  by  the  eruption  and  by  the  character  of  the 
remissions. 

Prognosis. — The  prognosis  is  always  favorable,  although 
the  symptoms  which  attend  its  development  may  be  alarm- 
ingly severe.  The  prognosis  is  only  unfavorable  when  it 
occurs  in  the  very  aged  or  in  feeble  infants. 

Treatment. — This  fever  always  runs  a  definite  course, 
and  its  treatment  is  the  symptomatic  treatment  of  fever, 
combined  with  well  recognized  anti-rheumatic  remedies. 

It  is  claimed  that  emetics  and  free  purgation  diminish 
the  intensity  of  the  fever.  A  favorite  combination  is  ipecac, 
calomel,  and  colchicum— these  to  be  administered  every 
night  in  cathartic  doses.  Calomel  should  never  be  admin- 
istered alone,  nor  in  combination  with  other  drugs,  if  its  spe- 
cific effect  is  likely  to  be  produced. 

The  administration  of  colchicum  with  spirits  of  nitre  and 
nitrate  of  potash,  in  such  proportion  that  profuse  diapho- 
resis may  be  produced,  in  connection  with  the  administra- 


TKEATMKXT.  17^ 

tion  of  cfforvescing  clraii,ii:hts,  will  usually  afTonl  relief  from 
the  i)ain  in  the  lu'ad  ami  rnMi)s.  Should  the  arthiitii-  ])ains 
still  be  felt,  o])iuin  may  he  administered  in  sudicient  quan- 
tity to  alVord  relief. 

J)urinii:  the  remission  tlie  bowels  should  be  ke])t  freely 
open  with  saline  i)Ui-i;atives,  and  quinine  combined  with  an 
alkali  should  be  given  at  stated  intervals.  Narcotics  ma}' 
be  uiven  in  small  doses  to  produce  sleep,  should  the  patient 
be  wakeful.  l\v  the  em])l(>yment  of  these  measures  a  return 
of  fever  mav  br  pivveiiipd  and  the  arthiitic  ])ains  will  grad- 
ually subside.  If  this  i)lan  is  i)ursued,  should  the  fever 
return,  it  will  be  mild  in  character,  atteiub'd  by  little  con- 
stitutional disturbance.  The  weakness  and  exhaustion 
which  attend  convalescence  may  l)e  combated  by  the  free 
use  of  wine  or  malt  liquors. 

The  diet  should  be  most  nutritious.  Nourishment  should 
be  administ(M-ed  at  stated  intervals,  during  the  night  as  well 
as  during  the  day. 

The  lymphatic  enlargement,  especially  in  the  inguinal 
region,  should  be  treated  locall}'  with  iodine. 

Citrate  of  iron  and  quinine  will  be  found  of  great  service 
during  the  convalescing  period.  If  a  single  joint  remains 
swollen  and  tender  for  a  considerable  period  after  the  sub- 
sidence of  the  fever,  the  occasional  application  of  a  blister 
is  recommended.  In  some  epidemics,  relapses  after  an 
interval  of  two  or  three  weeks  have  been  of  freqm^nt  occur- 
rence. They  run  a  milder  course  than  t\ui  primary  fever. 
The  relapses  more  closely  resemble  an  attack  of  articular 
rheumatism  than  they  do  the  primary  fever.  Quinine  is 
said  to  furnish  great  ])rotection  against  a  relapse. 

CHRONIC  MALARIAL  INFECTION. 

There  is  still  another  form  of  malarial  manifestation 
closely  connected  with  the  subject  which  has  been  engaging 
our  att<^ntion.  of  which  I  will  brietiy  speak.  It  has  be(»n 
termed  malaiial  cachexia,  or  better,  c/zro/^/V  mrtlarlal  infec- 
tion. I  do  not  include  it  in  the  list  of  malarial  fevers, 
although  it  may  be  a  se([uela  of  any  form  of  acute  malarial 


174  CHRONIC   MALARIAL   INFECTIOTTS. 

disease.  It  ma}'  be  developed  in  those  who  have  never 
suflfered  from  any  form  of  malarial  fever,  but  who  have 
resided  for  some  time  in  a  malarial  district.  For  instance, 
a  person  who  has  had  repeated  attacks  of  Intermittent  or 
remittent  fever,  and  has  become  exceedingly  anaemic,  with 
an  enlarged  spleen  and  enlarged  liver,  may  be  regarded  as 
in  a  condition  of  chronic  malarial  cachexia,  and  is  in  a 
condition  to  present  the  phenomena  of  chronic  malarial 
infection.  Again,  a  person  who  has  never  had  a  distinct 
paroxysm  of  malarial  fever,  but  who  has  lived  for  some 
time  under  malarial  influences,  the  malarial  poisoning  never 
having  been  intense,  becomes  anaemic  with  enlarged  spleen 
and  liver,  and  presents  the  phenomena  of  chronic  malarial 
infection. 

Morbid  Ax  atomy.— The  morbid  anatomy  of  chronic 
malarial  infection  does  not  differ  from  that  of  the  severer 
types  of  malarial  fever,  except  in  the  more  advanced  stages 
of  the  tissue- changes.  For  instance,  the  spleen  is  often  ten 
or  twelve  times  its  normal  size,  tough,  firm,  and  resistent. 
Its  surface  is  uneven,  its  capsule  enormously  thickened,  and 
more  or  less  adherent  to  the  adjacent  organs.  Its  substance 
is  rich  in  pigment  matter,  and  presents  the  minute  changes 
either  of  simple  hyperplasia  or  amyloid  degeneration.  Simi- 
lar tissue-changes  take  place  in  the  liver  and  kidneys.  In 
some  instances  the  muscular  tissue  of  the  heart  undergoes 
fatty  or  amyloid  degenerative  changes.  CEdema  of  the  sub- 
cutaneous cellular  tissue,  and  an  accumulation  of  fluid  in 
the  serous  cavities,  are  common  attendants  of  chronic  mala- 
rial cachexia. 

Etiology. — It  is  unnecessary  to  repeat  what  I  have  al- 
ready said  in  regard  to  the  causes  of  malarial  infection. 
It  may  be  the  result  of  prolonged  exposure  in  a  district 
only  slightly  malarial,  or  of  a  short  exposure  in  a  district 
strongJy  malarial. 

Symptoms.— Those  who  are  the  subjects  of  chronic  ma- 
larial infection  complain  of  vertigo,  ringing  in  the  ears,  loss 
of  memory,  disturbance  of  the  sight,  loss  of  appetite, 
nausea,  dyspeptic  symptoms,  and  jDain  and  oppression  in 
the  epigastrium.     The  bowels  are  rarely  constipated  ;  often 


in  tilt'  iiKirniiiij;  <liarr1i<va  is  ])rosont.  Tlic  slopp  is  clis- 
tiirlx'd  ;  it  \\\ny  In;  1)10^)1111(1,  l)ut  it  is  unrcfivsliiiig.  The 
])a(i('iit  awakes  in  tlio  nioniini;  with  aconfiiscd  feeling  about 
the  head  and  a  _i;-eneral  l'eeliii<;  of  discomfort.  Some  ('om- 
plaiii  of  ])ai!is  in  the  hack  and  loins  and  along  the  sciatic 
neivt' ;  others  complain  (•!'  i)ain  and  tenderness  in  the 
joints  and  stijrness  of  the  muscles  of  thf  liiiil)s  and  l)ack  ; 
they  iKM'ome  easily  fatign(^d  on  exertion,  c()!ii|)Iai!i  of  sliort- 
ness  of  breath,  and  have  i)alpitati()n  of  the  heart. 

The  iK'ivous  system  seems  to  suffer  most  severely.  One 
of  the  most  common  nervous  manifestations  is  local  anaes- 
thesia, which  usually  shows  its(?lf  upon  the  outer  surface  of 
the  thighs.  Not  unfiiMpieiitly  numbness  of  the  arms  and 
fingers,  and  tickling  and  burning  of  the  feet  are  com])lained 
of,  and  a  patient  will  consult  3'ou,  thinking  lie  is  about  to 
have  an  attack  of  paralysis.  Last  year  a  prominent  lawyer 
of  this  city,  suffering  from  chronic  malarial  infection,  came 
under  my  observation.  Sometimes  he  would  continue  an 
argument  in  court  half  an  hour  after  there  was  a  paitial 
loss  of  consciousness  ;  lie  would  afterwards  ask  his  ];ro- 
fessional  brethren  what  lie  had  said  Avhile  in  this  state. 

Hemiplegia  sometimes  occurs.  I  remember  one  case  in 
which  there  was  complete  loss  of  power  over  tlu'  right  arm 
and  leg,  yet  no  facial  paralysis.  This  patient  had  never 
liad  a  paroxysm  of  malarial  fever,  and  for  that  reason  the 
possibility  of  malarial  infection  had  been  excluded.  Simi- 
lar manifestations  of  chronic  malarial  infection  quite  fre- 
quently occur  in  those  who  have  never  had  a  distinct  ma- 
larial paroxysm. 

You  may  have  a  form  of  <'hronic  malarial  infection  unat- 
tended by  an}'  nervous  manifestations.  This  form  shows 
itself  in  catarrhal  intlammations  affecting  tin?  mucous  mem- 
brane of  the  stomach,  intestines,  and  bronchial  tubes. 
Patients  liave  a  form  of  bronchitis  which  is  really  a  chronic 
malarial  affection. 

A  gastro-enteritis,  in  which  there  is  marked  interference 
with  digestion,  may  be  developed  as  the  result  of  chronic 
malarial  infection.  If  this  is  treated  with  the  ordinary 
remedies  for  dysi)e]i«.i;i,    tio  good   result  is   accomplished, 


176  CHRONIC   MALAEIAL   INFECTIONS. 

while  a  few  doses  of  quinine  will  establish  the  diagnosis 
and  relieve  the  patient. 

The  chronic  catarrh  of  the  intestines  resulting  from 
chronic  malarial  poisoning  may  give  rise  to  a  troublesome 
diarrhoea,  which  will  assume  all  the  characteristics  of 
chronic  diarrhoea.  As  I  have  already  stated,  ansemia  is  a 
very  common  result  of  long-continued  malarial  poisoning, 
and  palpitation  of  the  heart  is  a  very  frequent  and  some- 
times distressing  accompaniment  of  such  anemia.  With 
many  persons  it  gives  rise  to  temporary  attacks  of  melan- 
cholia and  hypochondriasis.  Such  persons  imagine  they 
have  disease  of  the  heart,  or  kidney,  or  spine,  etc.  In  some 
cases  the  hypochondriasis  assumes  a  suicidal  character,  or, 
at  least,  the  individual  threatens  self-destruction,  though  I 
never  knew  one  to  do  any  harm  to  himself  during  tlie 
attack. 

Another  nervous  manifestation  of  chronic  malarial  infec- 
tion is  neuralgia.  Certain  nerve- trunks  or  their  roots  seem 
to  be  directly  affected,  while  the  nerve-centre  connected 
with  the  affected  nerve-trunks  escapes.  The  first  branch 
of  the  fifth  nerve  is  most  liable  to  be  affected  in  malarial 
neuralgia.  This  neuralgia  follows  a  periodic  course.  Per- 
sons over  forty  are  most  liable  to  be  affected  by  it.  Usual- 
ly the  nerve-trunks  first  affected  are  the  ones  involved  in 
successive  attacks ;  for  instance,  if  a  certain  intercostal 
nerve  is  the  seat  of  the  primary  neuralgic  paroxysm,  at 
each  subsequent  attack  this  particular  nerve  will  be  the 
seat  of  the  neuralgia. 

In  some  instances  chronic  malarial  infection  manifests 
itself  by  hemorrhages  from  the  mucous  surfaces,  such  as 
epistaxis,  haematemesis,  haematuria,  etc.  The  most  trouble- 
some case  of  menorrhagia  (occurring  independent  of  a 
mechanical  cause)  which  has  come  under  my  observation 
recovered  after  the  administration  of  large  doses  of  qiiinine, 
when  all  the  remedies  ordinarily  employed  in  such  cases 
had  failed  to  produce  the  desired  result. 

Recently  a  patient  came  under  my  observation  who  was 
in  a  scorbutic  condition,  with  spongy  gums,  and  with  large 
purpuric  spots  scattered  over  the  surface  of  the  body  ;  his 


DIFFERENTIAL    I)1A(;N0SIS.  177 

snrroiiiKVmijs  and  tin-  •■llVci  pi-ddiiccd  hy  aiili-iii;il:iri;d 
trcatiiK'iit  Irfr  little  doubt  in  my  mind  hut  that  chronic 
malarial  infection  was  the  cause  of  all  the  scorbutic  and 
pur])uric  manifestations. 

DiFFiMJKNTiAi.  DiA(;xos[s. — The  first  question  that  uou' 
arisi's  is,  how  can  you  decide  whether  these  manifestations 
to  which  1  have  icferred  are  malarial  or  non-malarial  ?  In 
the  majority  of  cases  there  will  be  some  eidargement  of  the 
sj)lei'n — it  may  be  only  ver}-  slight.  There  is  not  neces- 
sarily any  rise  in  temperature.  The  manifestations  will  be 
more  or  less  i)aro.\ysnuU.  If  the  patient  has  localized  aiues- 
thesia  or  liyperiiisthesia,  it  will  be  found  to  be  more  severe 
some  time  in  the  morning  or  evening.  If  he  has  lost  power 
over  one  portion  of  the  body,  he  will  lind  that  the  loss  of 
power  is  more  marked  at  a  certain  period  of  the  day.  The 
patient  may  not  observe  this,  unless  you  direct  his  atten- 
tion to  the  fact ;  then  he  will  readily  recognize  it.  It  is  for 
you  to  elicit  the  fact  by  a  careful  examination. 

You  will  also  find  in  the  severer  cases  of  chronic  malarial 
infection,  when  there  is  hemiplegia  or  some  structural 
change  affecting  the  mucous  membrane  of  the  stomach, 
intestines,  bronchial  tubes,  etc.,  that  there  are  also  evi- 
dences of  pigmentation  of  the  tissues.  Free  pigment  is 
frequently  found  in  the  blood.  It  is  not  found  in  those 
cases  where  the  malarial  jiosioning  is  slight,  where  it  is 
only  sufficient  to  ])roduce  ringing  in  the  ears  and  slight 
attacks  of  neuralgia,  perhaps  accompanitvl  by  slight  gastro- 
intestinal catairh  ;  but  when  the  malarial  ])oisoning  is 
sufficiently  inti-nse  to  cause  tem]»orary  loss  of  consciousness, 
hemi])legia,  or  any  other  of  the  sev<»rer  manifestations 
already  alluded  to,  even  though  there  has  been  no  distinct 
malarial  paroxys!u,  an  examination  of  the  blood  will  almost 
certainly  give  evidence  of  free  ])igmt'iitafion. 

The  diagnosis  of  chronic  malarial  infection,  to  a  certain 
extent,  depends  upon  the  circumstances  which  attend  its 
devrl(>]»nu-nt.  If  the  individual  has  repeatedly  suffered 
from  malarial  fever  paro.xysms,  or  if  he  has  resided  f(jr  some 
time  in  a  inahirial  district,  even  though  he  may  not  have 
had  a  distinct  malarial  ])aroxvsm,  thoimh  none  of  the 
12 


178  CIIKONIC   :\rALARIAL   IlSTFECTIOlSr. 

phenomena  to  wliicli  I  have  just  referred  have  been  de- 
veloped, and  though  that  peculiar  malarial  cachexia  which 
is  so  characteristic  of  malarial  poisoning  is  not  present,  yet 
it  is  always  well  to  carefully  consider  the  question  of 
malarial  infection. 

AVhile  the  manifestations  of  chronic  malarial  poisoning 
may  be  called  legion — and  in  many  instances  they  very 
closely  simulate  the  phenomena  of  other  diseases — still,  with 
a  histor}^  of  possible  malarial  exposure,  by  a  system  of  ex- 
clusion 3^ou  reach  the  fact  that  the  patient  is  suffering  from 
some  form  of  blood  poisoning.  When  you  have  reached 
that  conclusion  you  are  able  readily  to  determine  the  nature 
of  such  poisoning.  In  very  doubtful  cases  you  may  arrive 
at  a  diagnosis,  or  perhaps  confirm  an  uncertain  diagnosis 
by  treatment,  in  the  same  way  in  which  we  sometimes 
detect  syphilitic  infection  by  the  effects  of  treatment. 

Progn'OSIs. — The  prognosis  in  chronic  malarial  infection 
depends  upon  the  severity  of  its  manifestations.  The 
degree  of  enlargement  of  the  spleen  and  liver  is  a  reliable 
indication  of  its  severity. 

When  the  symptoms  are  mild  and  the  spleen  is  but 
slightly  enlarged,  and  when  neither  ascites  nor  oedema  of 
the  lower  extremities  is  present,  the  prognosis  is  generally 
good.  If  the  patient  is  very  anaemic,  the  spleen  very 
greatly  enlarged,  and  the  area  of  hepatic  dulness  very 
much  increased,  the  prognosis  is  unfavorable.  When  dis- 
tinct tumors  can  be  detected  in  the  spleen  and  liver,  they 
indicate  an  exceedingly  grave  form  of  malarial  infection  ; 
if  the  tumors  are  large,  they  can  rarely  be  reduced.  If  the 
individual  in  whom  these  tumors  are  found  removes  from 
a  malarial  district,  a  long  time  may  elapse  before  they  ap- 
parently very  much  interfere  with  his  health  and  comfort. 

You  must  take  into  consideration  the  possibility  of  your 
patient  being  able  to  take  up  his  permanent  residence  in  a 
non-malarious  region,  before  you  make  a  prognosis  in  any 
given  case. 

So  long  as  such  a  patient  is  under  malarial  influences, 
however  slightly  malarial  they  may  be,  the  progress  of 
the  disease  cannot  be  permanently  arrested  ;  and  when  the 


'lUKATMKXT.  179 

manifestations  of  thegrav.'i-  forms  of  lualaiiul  iiifrctioii  :ir«» 
l)ivsciit,  tlii'iv  is  little  prosjx'ct  I  hat  the  disease  can  be  t<'ni- 
jKnaiily  ivli.'vcd  so  long  as  the  patient  remains  in  tiie 
mahiiial  <listriet. 

TiiKAT.MK.NT.— The  tii'st  anil  most  imi)ortant  thing  to  be 
aceoinplished  in  the  treatment  of  ehronic  malarial  infection 
/.v  the  removal  of  the  individual  from  a  malar  iou.s  district 
to  a  hi(/h,  warm,  moiinfainous  region.  It  is  of  the  great- 
est importance  that  all  exposnre  to  wet  and  cold,  and  the 
damp  air  of  the  evenings  and  nights,  should  be  avoided  ; 
th.'  slei'])ing  apartments  must  be  dry  and  airy,  and  Ihinii.-l 
should  be  worn  next  to  the  skin. 

So  long  as  the  thermometer  shows  even  a  slight  febrile 
movement,  quinine  must  be  given  in  full  doses.  If  aufemia 
is  present,  which  is  usually  the  case,  iron  must  be  combined 
with  the  quinine,  and  administered  immediately  befcjre  or 
after  taking  food. 

In  those  cases  in  which  the  spleen  and  liver  are  very  much 
enlarged,  when  no  febrile  excitement  is  present,  iodide  if 
iron  combined  with  cod-licer  oil  icill  be  found  of  great 
service. 

It  is  claimed  by  some  that  muriate  of  ammonia  has  a 
very  beneficial  effect  in  this  class  of  cases,  but  my  own 
experience  does  not  lead  me  to  favor  its  use. 

If  the  bowels  are  constii)ated,  aloes  or  rhubarl)  should  be 
given  in  connection  with  some  of  the  chlorine  mineral  waters. 
In  those  cases  in  which  the  measures  already  referred  to 
fail  to  produce  any  improvement  or  affoid  any  permanent 
relief,  arsenic  may  be  resorted  to,  but  the  effects  of  the 
drug  must  be  carefully  watclied,  and  on  tlie  ai»])earance  of 
crdema  or  of  gastric  disturbance,  it  must  be  ])romi)tly  dis- 
continued. It  must  be  borne  in  mind  that  the  use  of  all 
these  therajxHitic  ag.Mits  is  not  sufficient  ;  pro])er  attention 
must  be  i)aid  to  hygienic  measures. 

The  neuralgias  which  are  such  frequent  manifestations  of 
this  infection  are  best  treated  bv  combining  a  full  dose 
of  opium  with  large  doses  of  (piinine.  If  ])aralysis  is  a 
manifestation  of  the  malarial  i)oisoning,  strychnine,  iron, 
and  <piinine   may  be  combined  in  its  treatment,   in   con- 


180  CHRONIC   MALARIAL  USTFECTION". 

nection  witli   cold  douclies  and  friction  to  the  paralyzed 
limbs. 

A  most  nutritious  diet  and  a  liberal  use  of  good  wine  is 
indicated  in  all  cases  of  chronic  malarial  infection.  The 
daily  use  of  brandy  in  small  quantities  is  of  great  service. 

I  will  add  a  few  words  in  regard  to  the  use  of  quinine  in 
this  class  of  cases.  I  am  convinced  that  the  indiscriminate 
use  of  this  drug  often  does  harm.  After  fairly  testing  its 
effects,  if  no  relief  is  obtained,  its  use  should  be  discon- 
tinued for  a  time,  or  at  least  until  the  beneficial  effect  of  a 
removal  from  a  malarial  district  is  tried,  or  until,  by  the  use 
of  mild  cathartics  and  the  daily  administration  of  cod-liver 
oil  and  iron,  the  patient  is  in  a  condition  to  be  benefited  by 
it.  Quinine  seems  to  have  no  effect  upon  many  persons 
suffering  from  the  severe  manifestations  of  this  infection,  so 
long  as  they  remain  in  a  malarial  district.  It  is  of  the 
greatest  importance  that  you  should  early  make  yourself 
familiar  with  the  condition  in  wdiicli  quinine  is  indicated 
in  the  treatment  of  this  class  of  affections.  Let  me  impress 
upon  3^ou  the  importance  of  avoiding  depressing  remedies 
in  all  forms  of  chronic  malarial  infection.  Drastic  cathar- 
tics, exhausting  diaphoretics,  and  all  other  depressing 
remedies  must  be  carefully  avoided.  They  do  great  harm 
by  exhausting  the  already  enfeebled  vital  powers.  Espe- 
cially is  this  true  in  regard  to  the  free  use  of  mercurials, 
which  are  so  commonly  resorted  to  in  their  management. 
Unquestionably,  an  occasional  cathartic  dose  of  calomel  is 
of  service,  but  the  administration  of  small  doses  repeated 
after  short  intervals,  in  order  to  produce  the  constitutional 
effects  of  the  drug,  will  always  be  followed  by  the  more 
serious  manifestations  of  the  malarial  infection. 

The  exhausted  system  of  this  class  of  patients  needs  rest, 
concentrated  nutrition,  and  the  supporting  influence  of  a 
change  of  climate  and  tonics. 


LECTURE   XVI. 


TYPIIO-MALAUIAL  FEVER. 
In troduction. — Morbid  Anatomy.  — Etiology. — Symptoms. 

I  .SJIALL  this  moi'iiiiig  commence  the  history  of  t^'jjho-ma- 
larial  fever.  I  liave  included  this  fever  in  the  list  of  the 
malarial  fevers,  although  it  is  not  altogether  malarial  in  its 
origin  ;  malarial  poison,  however,  is  so  essential  to  its  de- 
velopment that  it  may  very  properly  be  regarded  as  one  of 
the  malarial  fevers. 

As  its  name  indicates,  it  has  many  elements  in  common 
with  typhoid,  and  many  which  ally  it  to  remittent  fever. 
To  the  term  '•  tyi>ho-malarial  "  different  signiiications  have 
been  given  by  dilferent  observers.  By  one  class  the  term 
has  been  employed  to  indicate  the  presence  of  malaria,  and 
also  the  specific  poison  which  produces  typhoid  fever. 

By  anotlier  class  of  observers  the  term  has  been  employed 
to  indicate  the  presence  of  malaria,  and  also  a  septic  i)oison 
which  differs  from  the  speciiic  poison  that  gives  rise  to  ty- 
phoid fever. 

There  is  still  anotlier  class  of  observers  who  doubt  the 
existence  of  such  a  form  of  fever,  and  regard  the  so-called 
t3'])lioid  element  as  nothing  more  than  a  ''  typhoid  con- 
dition/' liable  to  be  develojted  in  connection  with  remittent 
fever,  as  well  as  many  other  diseases. 

The  term  ty})ho-nialarial  is  a  convenient  one  for  the  first 
class  of  observers,  and  is  one  which  can  be  em])loyed  by 
them  without  confusion  :  wlicn-as,  for  thf  second  class  of 
observers,  it  is  exceedingly  inconvenient,  giving  rise  to  con- 


182  TYPITO-MALAEIAL  FEVER. 

fusion,  because  it  does  not  embrace  the  views  held  by  them 
regarding  the  etiology  of  the  disease. 

But  we  have  the  term,  and  I  shall  employ  it  as  one  denot- 
ing a  fever  which  is  produced  by  the  combined  action  of  a 
septic  and  a  malarial  poison.  As  far  as  possible  I  shall 
use  the  word  septic  when  speaking  of  the  poisons  which 
are  associated  in  the  production  of  the  disease,  and  the 
term  typhoid  will  be  reserved  for  that  peculiar  condition 
known  as  tlie  "  typhoid  condition,"  and  for  the  specific  dis- 
ease known  as  typhoid  fever.  You  will  meet  with  some 
cases  of  typho-malarial  fever  in  which  the  septic  element 
predominates,  and  others  in  which  the  malarial  element  is 
predominant.  The  preponderance  of  the  leading  features 
of  the  one  or  the  other  of  these  two  forms  of  fever  will 
enable  you  to  determine  with  a  good  degree  of  certainty 
the  course,  prognosis,  and  treatment  of  each  individual  case. 
The  distinguishing  lines,  however,  between  these  two  ele- 
ments are  not  always  sharply  defined,  but  almost  impercep- 
tibly the  symptoms  dependent  upon  one  poison  become 
mingled  with  those  developed  by  the  other.  Both  of  these 
elements  may  be  modified  in  their  manner  of  development 
and  in  their  morbid  anatomy,  by  the  occurrence  of  various 
intercurrent  complications,  such  as  scurvy,  pneumonia,  etc. 

Morbid  Anatomy.— The  changes  which  take  place  in  the 
constituents  of  the  blood  in  typho-malarial  fever,  so  far  as 
we  are  yet  able  to  determine,  are  similar  to  those  which 
occur  in  typhoid  fever,  combined  with  those  which  are  char- 
acteristic of  malarial  fever  ;  the  presence  of  free  pigment 
granules  in  the  blood  is  often  a  strong  point  in  its  differen- 
tial diagnosis. 

In  connection  with  these  blood  changes,  there  are  more  or 
less  parenchymatous  changes  in  the  internal  organs  similar 
to  those  met  with  in  other  forms  of  fever  and  in  acute  in- 
fectious diseases.  The  liver  is  increased  in  size,  and  its  cut 
surface  presents  an  appearance  which  closely  resembles  that 
known  as  nutmeg  liver.  Sometimes  it  presents  the  peculiar 
bronzed  color  of  the  liver  in  remittent  fever  ;  at  other  times 
it  very  closely  resembles  the  liver  of  yellow  fever.  A  mi- 
croscopical examination  shows  free  fat  and  more  or  less 


:m()K1!I1)  anatomy.  183 

bro'.vn  ])i,i;ni(Mit  graiuilrs  in  tli«'  licpatio  fells.  In  mosf  r-n-^r"? 
of  this  fever  the  splcrn  is  enl:ir<;ed,  softened,  and  of  an  al- 
most Mack  eolor.  The  Mali)iuhian  bodies  are  prominent, 
and  ]iresent  the  aiijM'aiance  on  the  torn  surface  of  the  spleen 
of  little  tumors,  which  vary  in  size  from  a  ])in's  head  to  that 
of  a  pea.  'i'he  orn-an  is  rarely  as  much  enlarged  or  softened 
as  in  tyi)lioid  or  remittent  fevers.  It  is  always  the  seat  of 
more  or  less  ])igmentation. 

No  uniform  change  will  be  noticed  in  the  Jcklneijs,  except 
that  of  hypiTjrniia,  which  Avill  be  most  marked  in  their  cor- 
tical substance. 

The  Itmr/s  at  their  most  depending  portion  are  the  seat  of 
more  or  less  extensive  hypostatic  congestion.  Splenization 
of  the  lungs  is  not  as  frequently  present  as  in  typhoid  fever. 

The  l/rort  is  pale  and  flabby.  Its  muscular  fibn^s  ai-e  the 
seat  of  a  granular  degeneration  similar  to  that  which  takes 
place  in  the  heart  in  typhoid  fever.  Exsanguinated  clots 
more  or  less  iirm  may  be  found  in  its  cavities,  but  they 
have  nothing  peculiar  about  them.  They  closely  resemble 
those  found  in  ]iersons  who  have  died  from  failure  of  heart 
power.  They  ai'e  larely,  if  ever,  the  direct  cause  of  death. 
My  own  examinations  of  the  intestinal  lesions  of  this  fever 
have  led  me  to  adopt,  for  the  most  part,  the  descriptions 
which  have  been  published  by  Dr.  J.  J.  Woodward,  of  the 
U.  S.  A.  In  fact.  Dr.  Woodward's  investigations  in  this 
direction  may  be  regarded  as  exhaustive.  That  the  intes- 
tinal changes  of  typho-malarial  fever  very  closely  resemble 
those  of  typhoid  fever  there  can  be  no  (question  ;  b}"  some 
the}'-  have  been  regarded  as  identical,  but  I  think,  if  we  vi^ry 
carefully  observe  them,  some  very  marked  differences  can 
be  recognized  ;  especially  if  we  attempt  to  divide  the  stages 
of  their  development  into  periods  so  as  to  correspond  to  the 
days  and  weeks  of  the  fever,  as  is  possible  with  the  intes- 
tinal changes  of  typhoid  fever. 

As  in  typhoid  f(wer,  the  principal  and  almost  constant 
changes  are  to  be  found  in  and  around  the  closed  follicles 
of  tile  intestinal  tract.  These  changes  are  made  n)anifest 
by  the  gradual  enlargement  of  the  follicles,  which,  as  tluy 
enlarge,  become  more  or  less  pigmented. 


184  TYPiio-:\rALArwiAL  fever. 

xVt  tlie  post-mortem  examination  of  one  who  has  died  of 
this  fever,  you  will  usually  tind  these  glands  in  all  stages 
of  this  pathological  process,  from  slight  enlargement  and 
softening  to  ulceration  of  the  entire  follicle.  The  summit 
of  the  enlarged  follicle  is  the  first  seat  of  the  ulcer.  These 
ulcers  may  involve  a  single  follicle,  or  they  may  invade  the 
adjacent  mucous  membrane,  and  produce  ulcers  from  one- 
half  an  inch  to  an  inch  in  diameter.  The  largest  and  most 
extensive  ulcerations  are  to  be  found  in  the  ileum  and  in- 
volving the  Peyerian  patches.  The  edges  of  these  ulcers 
are  irregular  and  everted  ;  their  base  is  usually  of  a  grayish 
color,  often  mottled  with  black  points.  These  ulcers  may 
extend  into  the  submucous  tissue  and  involve  the  muscular 
coat  of  the  intestine,  and  even  perforate  the  peritoneal 
covering  of  the  intestines. 

In  the  earlier  stages  there  is  little  to  distinguish  these 
intestinal  changes  from  similar  ones  which  develop  in  ty- 
phoid fever,  except,  perhaps,  the  tendency  to  the  deposit  of 
black  pigment  in  the  enlarged  follicles.  In  a  later  stage, 
certain  peculiarities  are  present,  which  are  often  sufficiently 
distinctive  to  designate  the  case  as  one  of  typho-malarial 
fever.  For  instance,  in  typho-malarial  fever  there  is  a  grad- 
ual elevation  of  the  mncous  membrane  surrounding  the 
enlarged  follicles,  which,  if  ulcers  exist  on  their  edges, 
reaches  a  thickness  of  from  three  to  six  lines. 

These  ulcers  differ  from  those  of  typhoid  fever  in  that 
the  enlarged  patch  rises  abruptly  from  the  mucous  mem- 
brane, and  in  such  a  manner  that  the  summit  is  often 
larger  than  the  constricting  base.  Besides,  the  umbilical 
depression  so  often  seen  in  ordinary  typhoid  patches  prior 
to  ulceration  is  rarely  observed  in  typho-malarial  fever. 
As  I  have  already  stated,  the  ulcers  in  typho-malarial  fever 
present  ragged,  irregular  edges,  which  are  usually  exten- 
sively undermined,  in  consequence  of  the  erosions  ex- 
tending into  the  submucous  tissue,  rather  than  into  the 
glandular  layer  of  the  mucous  membrane.  This  undermin- 
ing of  the  edges  is  much  more  extensive  than  in  typhoid 
ulcers. 

The  mucous  membrane  between  the  follicles  presents  the 


Mor>r!TD  AXATo^rr.  1,95 

ordinmy  appoarnnre  oC  catanlial  iiillaininafion,  naim'ly, 
th(Mv  is  more  or  less  coiif^estion,  timu'ractioii,  and  in  the 
later  stages  thickening  and  softening  of  its  tissue. 

Tlie  minute  anatomical  changes  which  att('n<l  the  dt'vdop- 
ment  of  these  intestinal  lesions,  as  determined  by  the  niicro- 
sco]>e,  do  not  essentially  differ  from  those  which  I  have 
already  described  as  occurring  in  ty})hoid  fever,  except  that 
they  have  no  regular  stage  of  development  marked  by  days 
and  weeks,  the  processes  are  slower  in  their  develo})ment, 
and  the  presence  of  ]ugnient  in  the  enlarged  and  ulcerating 
follicles  stamp  it  as  depending  upon  an  essentially  different 
exciting  cause.  Hence,  although  the  intestinal  lesions  of 
this  fever  very  closelv  resemble  those  of  typhoid,  tliey  are 
not  identical,  but  evidently  belong  to  another  type  of  dis- 
ease. Undoubtedly,  there  are  cases  in  each  of  these  two 
forms  of  fever  between  which,  by  the  intestinal  lesions  alone, 
it  is  impossible  to  draw  the  line  of  distinction  ;  but  in  typi- 
cal cases  this  is  easily  done. 

Intestinal  perforation,  and  a  consequent  peritonitis,  the 
result  of  the  intestinal  ulc(^ration,  may  occur  in  typho- 
malarial  fever,  but  you  will  rarely  meet  with  such  an  acci- 
dent. Usually  the  mesenteric  glands  are  more  or  less  en- 
larged, and  in  the  advanced  stages  of  the  disease  more  or 
less  softened.  They  are  of  a  livid  color,  and  more  or  less 
pigmented.  The  greatest  enlargement  of  these  glands  will 
be  found  in  that  portion  of  the  mesentery  which  corresponds 
to  the  most  extensive  and  advanced  intestinal  changes. 

The  principal  changes  in  the  structure  of  the  glands  are 
similar  to  those  which  occur  in  a  purely-  inllamniatory 
process. 

Occasionally,  minute  ulcers  are  met  Avitli  in  the  mucous 
membrane  of  tin*  stomach  and  large  intestines,  and  the  mu- 
cous membrane  of  the  stomach  is  not  unfrequently  very 
greatly  softened,  and  the  mucous  membrane  of  the  huge 
intestine,  if  there  have  been  any  manifestations  of  scurvy 
during  the  progress  of  the  fever,  will  be  thickened  and 
softened,  perhaps  extensively  ulcerated,  presenting  an  ap- 
pearance, in  some  instances,  clo.sely  resembling  those  found 
aft(T  death  in  chronic  malarial  dvsenterv.     "NViiile,  there- 


186  TYPIIO-MALAEIAL   FEVER, 

fore,  we  find  no  pathological  lesions  wlilcli  can  be  regarded 
as  characteristic  of  tliis  type  of  fever,  and  while  the  lesions 
which  we  do  find  very  closely  resemble  those  of  typhoid 
fever  on  the  one  hand,  and  remittent  fever  on  the  other, 
still  there  are  marked  difi'erences  which  distinguish  it  from 
either  of  these  fevers  sufficiently  to  stamp  it  as  a  distinct 
type  of  fever. 

Etiology. — It  is  difficult  to  determine  the  trne  etiology 
of  typho- malarial  fever.  That  malarial  poison  is  necessary 
for  its  development  there  can  be  no  question.  It  is  equally 
certain  that  some  other  poison  besides  malaria  is  in  opera- 
tion whenever  this  fever  prevails.  That  this  poison  is  not 
the  specific  poison  of  typhoid  fever  is  apparent  from  the 
fact  that  its  development  and  spread,  as  far  as  can  be  de- 
termined, is  in  no  way  connected  with  the  excrements  of 
one  suffering  from  this  fever. 

There  are  a  few  facts  connected  with  its  development 
which  are  now  well  established  : 

First. — It  is  only  met  with  in  malarial  districts. 

Second. — In  the  majority  of  instances,  when  this  fever  has 
prevailed,  its  develoj^ment  has  been  preceded  or  attended 
by  marked,  and  easily  recognized,  anti-h3^gienic  conditions, 
such  as  overcrowding,  bad  sewerage,  and  other  conditions 
favorable  to  the  development  of  septic  poison. 

Tliird. — That  it  is  a  non-contagious  clisease,  and  is  never 
propagated  from  the  affected  to  the  healthy,  either  directly 
by  personal  contagion,  or  indirectly  by  morbid  excretions. 

Fourth. — In  its  morbid  anatomy  and  symptomatology  it 
is  a  combination  of  two  well  recognized  forms  of  fever.  The 
special  symptoms  and  lesions  of  one  or  the  other  of  these 
fevers  stamp  its  character,  and  indicate  its  alliance  to  a  ma- 
larial or  septic  type  of  fever. 

In  large  cities,  in  which  malarial  diseases  are  prevalent, 
sewer  gases  seem  to  furnisTi  the  se'ptic  element  which  is  so 
necessary  for  the  development  of  this  type  of  fever.  The 
history  of  disease  in  our  own  city  during  the  past  few  years 
furnishes  striking  examples  of  the  combination  of  these  two 
poisons  in  developing  a  type  of  fever  which  it  seems  to  me 
must  be  classed  under  this  head. 


SVMI'IOMS.  187 

Symptoms.— It  is  ov.mi  moiv  diHiculi  to  prosont  a  tyi)icnl 
l)'R'tuiv  of  tliis  IVvcr  ihaii  of  l.vplioi<l.  To  uivc  you  rv.-ii 
an  outline  of  its  synii)toius  w  hicli  shall  br  a|>i>ro.\iMi:itily 
Irui-  of  all,  oi-  cvt'U  llie  majority  t)f  cases,  is  iiupossil)le.  lis 
clinical  history  vaiics  as  the  malarial  or  septic  eh^nient  pre- 
dominates. Besides,  there  are  a  huf^e  numbt^-  of  cases  in 
which  neither  of  these  elements  can  be  said  to  predominate, 
for  the  ]>alient  almost  insmsiMy  ])asses  from  a  malarial  into 
a  typhoid  condition.  Theiv  ai'-  also  certain  anti-hyi!;i<'nic 
conditions  uhicli  may  be  ])resent,  which  f^ive  to  the  fever  an 
nnusual  and  jifculiar  type.  For  example,  when  those  con- 
ditions exist  which  favor  the  development  of  scurvy,  if 
typho-malarial  f<'v<'r  is  ])revailing,  as  the  patient  enters 
upon  the  s(H'ond  week  of  the  fever  the  scoi-butic  ]>h(Mio- 
nicna  will  become  jirominent. 

At  times  the  dysenteric  element  may  be  engrafted  on  this 
fever,  which  shall  greatly  modify  its  course,  and  lead  to  a 
train  of  symptoms  and  morbid  changes  which  shall  veiy 
closely  ally  it  to  ei>i(li'iiiic  dysentery. 

The  course  of  this  fever  may  also  be  greatly  modili((l  by 
certain  local  complications  which  are  especially  liable  to 
occur  during  the  second  or  third  week.  The  presence  of 
any  of  these  conditions  will  greatly  change  its  clinical 
liistory,  but  the  i)henomena  which  attend  its  early  develop- 
ment will  always  be  sufficient  to  determine  its  true  character. 

In  considering  in  detail  tin'  symptoms  of  this  fevtM-.  I  will 
iirst  di'scribe  that  class  of  cases  in  which  the  malarial  da- 
ment  is  predominant. 

This  ty])e  of  fever  is  usually  ushered  in  by  a  distinct  chill. 
In  some  instances  no  premonitory  symptoms  are  present,  in 
other  cases  the  chill  is  preceded  by  wandering  pains  in  the 
limbs  and  back,  headache,  loss  of  appetite,  and  a  feeling  of 
great  exhaustion.  In  a  huge  ])roportion  of  cases,  in  the 
early  stage,  the  countenance  has  a  ])eculiar  waxy,  clay- 
colored,  or  yellowish  tinge.  The  chill  varies  in  duration 
from  half  an  hour  to  an  hour,  and  in  character  closely 
resembles  the  chill  of  simph'  ivmlttent  ftvir.  It  is  inime 
diately  followed  l)y  active  ft.-brile  symptoms,  the  temjtera 
ture  rising  in  a  f.-w  hours  to  KKJ"  F.  or  loi"  F.     The  pulse 


188  TYPHO-MALARIAL   FEVER. 

readies  100,  and  is  full  and  forcible.  The  excretions  are  all 
cluH'ked,  and  there  is  mental  disturbance  and  sometimes 
delii'iuni.  When  once  established,  the  fever  pursues  a 
variable  course.  At  its  onset,  and  for  the  first  few  days,  its 
phenomena  often  closely  resemble  those  of  simple  remittent 
fever,  though  the  remissions  are  never  so  well  defined  as  in 
remittent,  and  there  is  at  the  very  onset  of  the  fever  an 
amount  of  intestinal  disturbance  which  is  rarely  present  in 
sinii)le  remittent.  The  existence  of  abdominal  tenderness, 
especially  in  the  right  iliac  fossa,  is  a  strong  point  in  the 
differential  diagnosis  of  typho-malarial  and  simple  remit- 
tent fever  in  favor  of  the  former.  As  the  temperature  rises, 
nausea,  vomiting,  and  epigastric  tenderness  are  present  in 
a  greater  or  less  degree.  These  gastric  symptoms  bear  a 
close  resemblance  to  those  which  attend  the  development  of 
remittent  fever,  while  the  intestinal  and  abdominal  symp- 
toms are  similar  to  those  of  typhoid  fever.  Diarrhoea  may 
precede  the  chill  ;  in  most  cases  it  is-  present  during  the 
period  of  fever.  At  first  the  tongue  presents  a  pale,  flabby 
appearance,  with  a  smooth  surface ;  soon  it  becomes  covered 
with  a  white  or  yellowish-white  coating ;  later  it  becomes  red 
and  the  coating  becomes  brownish ;  in  severe  cases  it  may 
suddenly  become  clean,  red  and  shining,  and  sordes  may 
collect  upon  the  teeth  and  lips. 

In  those  cases  in  which  a  scorbutic  element  exists,  the 
tongue  is  enlarged,  pale,  and  flabby,  its  surface  smooth 
and  covered  with  a  white  fur,  which  is  thickest  on  its  edges, 
the  gums  are  swollen  and  present  the  characteristic  appear- 
ance of  scurvy. 

In  those  cases  in  which  a  dysenteric  element  is  present  as 
the  fever  develops  the  dysenteric  symptoms  become  promi- 
nent, the  discharges  from  the  bowels  are  blood-stained  and 
watery.  The  tongue  soon  becomes  dry  and  brown,  and  the 
patient  shows  signs  of  extreme  exhaustion,  with  few  of  the 
gastric  symptoms  which  are  usually  so  well  marked  in  the 
early  period  of  the  fever. 

Throughout  the  whole  course  of  the  disease  there  is  a 
marked  tendency  to  periodicity,  the  exacerbations  usually 
assuming   a  tertian  type.     In  fatal  cases,  as   the  patient 


SYMPTOMS.  189 

reacli«\s  tlic  second  or  tliiid  wrck,  the  symptoms  are  very 
like  those  of  fatul  tyi»lioicl  ieVL-r :  the  i)rostratioii  IxM-omes 
moit'  and  more  eom])k'te,  tlie  pulse  readies  130  or  140,  is 
feebh-  aiul  irrfuiilai-,  the  ])atient  ^nadiially  passes  into  a 
state  of  stui)or  and  coma,  involuntary  evacuations  take 
place,  and  death  ensues. 

In  cases  that  recovei-,  symi)t(jms  of  anit'iidinrnt  nia\'  ])ii 
noticed  V)etw«'en  tlie  tenth  and  twrntiftli  thiys.  The  ton,ii;ue 
begins  to  become  clean,  the  al)dominal  symptoms  subside, 
the  pulse  becomes  less  frequent  and  fullt-r,  tin- distuibance 
of  the  nervous  system  disai)])ears,  the  a])i»etite  gradually 
returns,  and  the  patient  enters  upon  a  tedious  convales- 
cence, which  is  attend(»d  by  more  or  less  diarrhoea,  mental 
stupor,  cardiac  irritability,  and  a  slow  return  of  mental  and 
pliysical  vigor. 

The  train  of  symptoms  thus  l)rieliy  sketched  may  be 
greatly  nioditied  by  a  variety  of  complications.  Not  unfn.'- 
queutly  pulmonary  complications  develop  during  its  second 
week,  and  so  change  its  phenomena  that  the  fever  element 
may  be  overlooked  and  the  pulmonary  element  alone  engage 
the  attention  of  the  physician. 

Suppurative  intiammation  of  the  cervical  and  inguinal 
glands  sometimes  compli<'ates  this  type  of  fever,  and  leads 
one  to  the  mistake  of  regarding  it  as  purely  a  suppurative 
fever. 

Again,  scurvy  under  certain  anti-hygienic  conditions  may 
so  modify  the  usual  phenomena  of  ty])ho-nuilarial  fever, 
that  it  has  led  some  to  regard  this  fever  when  developed 
under  such  circumstances  as  an  entirely  new  type  of  fever, 
entirely  losing  sight  of  its  malarial  elemtmt,  and  classing  it 
among  the  infectious  fevers.  The  scorbutic  element  in  this 
class  of  cases  is  developed  in  connection  with  the  malarial 
exposure. 


LECTURE   XVII. 


TYPHO-MALARIAL    FEVEE. 

Symptoms  {continued).  — Differential  Diagnosis.  — Progno- 
sis. — Treatment. 

I  HAVE  mentioned  tlie  prominent  symptoms  which  attend 
the  development  of  that  type  of  typho-malarial  fever  in 
which  the  malarial  element  predominates,  and  will  now 
speak  of  those  present  in  the  seiytic  type  of  this  fever. 
Although  the  premonitory  symptoms  of  this  type,  such  as 
lassitude,  headache,  pains  in  the  back  and  limbs,  resemble 
those  of  typical  typhoid  fever,  either  a  distinct  chill  or  a 
complete  intermittent  or  remittent  paroxysm  ushers  in  the 
febrile  symptoms. 

The  rise  in  temperature  following  the  ushering-in  chill  has 
no  typical  range ;  in  some  cases  the  rise  is  gradual,  not 
reaching  its  maximum  before  the  middle  of  the  second  week  ; 
in  other  cases  the  rise  is  sudden,  reaching  104°  F.  or  105°  F. 
within  twent3^-four  hours  after  the  occurrence  of  the  chill. 
Throughout  the  whole  course  of  the  fever  the  same  tendency 
to  periodicity  exists  which  was  noticed  in  the  malarial  type 
of  this  fever. 

In  typhoid  fever,  during  the  first  week,  there  are  indis- 
tinct forenoon  remissions  and  afternoon  exacerbations,  but 
in  this  fever  the  remissions  are  well  marked,  especially  on 
every  second  or  third  day,  causing  the  fever  to  assume  a 
more  or  less  distinct  tertian  or  quartan  type.  One  of  the 
earliest  symptoms  is  well-marked  hepatic  tenderness  ;  with 


SYMPTOMS.  101 

tlit^  iH'pat'u^  t«'iul('rnesa  then?  is  (MilarujtMiiont  of  (li<*  si)let'ii, 
which,  us  the  IVvlt  proi::n'SS('s,  reaches  a  imicli  lar;i;ei-  size 
than  is  ordiiiaril}-  met  with  in  lyi)h()id  f.-Nci-.  I)iii-in,<^  the 
first  vveels.  the  piiNc  is  full  ;iiid  lar.-lv  iiioiv  liiaii  IdO  heats 
per  minute,  but  duriiii;-  ih'-  second  and  third  wt^eivs  it  is 
small  and  c<)inpi'essil)le,  and  in  severe  cases  iutermitteut, 
and  ranges  IVoni  1  JO  to  i:}ti  prr  minute.  The  appearance  of 
the  tom;ue  Aaries  with  the  period  of  the  fever.  At  lirst  it 
is  swolh'U,  with  red  ])rojectin,u-  ])a})ilh*e,  and  lias  a  li^ht 
wliiti'  coating.  As  the  typhoid  condition  l»ecomes  more 
})roininent  its  a])i)earan('e  changes;  it  becomes  dry  and 
brown,  and  fie(pieiitly  the  brown  coating  cracks,  and 
fissures  are  formed  in  tlie  mucous  membrane  uiKh-nieatli. 
Should  the  tongue  become  moist  and  begin  to  clean,  you 
may  regard  convalescence  as  established.  The  coating  is 
removed  in  two  ways,  either  gradually  from  the  edges  to  tlie 
centre,  or  it  is  thrown  off  in  Hakes.  In  the  lattin-case,  after 
tlie  removal  of  the  coating,  the  tongue  assunu'S  a  beefy 
red  appearance,  and  after  a  short  time  may  again  bciome 
brown  and  dry.  Under  such  circumstances  there  will  be  a 
renewal  of  the  fever-sj'mptoms. 

After  the  fever  has  continued  a  few  days  the  surface 
becomes  dry  and  harsh,  and  the  skin  assumes  a  bronzed 
hue,  which  is  quite  characteristic  of  this  fever  ;  sometimes, 
instead  of  this  bronzed  hue  of  the  surface,  there  is  well- 
marked  jaundice. 

The  changes  in  the  mine  do  not  dill'er  IVoin  those  which 
usuall}'  attend  febrile  excitement.  The  urint?  gradually 
diminishes  in  quantity  and  decj»ciis  in  color  until  convales- 
cence commences,  when  it  increases  in  ([uantity  until  con- 
valescence is  reached.     It  is  rarely  albuminous. 

Dlarrhdca  may  occur  at  any  ]ieriod.  It  is  not  usually 
excessive  until  the  second  or  third  week.  There  is  nothing 
cliaracteristic  about  the  discharges.  They  are  usually  of 
an  exceedingly  f«^tid  odor,  water}^  ami  dark-colored  ;  in  tim 
later  stag(\s  of  the  disease  they  sometimes  contain  blood. 
In  sonu'  instances  the  character  of  the  stools  is  termed  bil- 
ious, and  an  exn-essive  hejKitic  secretion  is  then  indicated  ; 
at  oth"r  limes  they  are  of  a  dark  clay  color,  showing  a  de- 


192  TYPnO-MALARIAL   FEVER. 

ficioncy  of  tlie  biliary  secretion.  With  tlie  diarrhoea  there 
is  usuall}'^  more  or  less  abdominal  tenderness,  especially  in 
the  right  iliac  region;  but  the  tympanitis,  which  is  so  con- 
stant an  attendant  of  typhoid  fever,  is  rarely  well  marked 
in  typho-malarial  fever.  In  many  cases  there  is  retraction 
of  the  abdomen. 

As  I  have  already  stated,  headache  is  a  very  constant 
and  prominent  symptom  in  the  early  period  of  this  fever. 
It  often  precedes  the  ushering-in  chill.  As  the  fever  pro- 
gresses it  gives  place  to  a  delirium,  which  is  never  violent, 
but  which  is  muttering  in  character,  and  is  attended  by  rest- 
lessness and  insomnia,  or  by  drowsiness,  subsultus,  picking 
at  the  bed-clothes,  and  great  nervous  prostration.  If  deli- 
rium is  not  present,  or  after  it  has  disappeared  during  con- 
valescence, there  is  great  lack  of  mental  vigor  and  a  ten- 
dency to  mental  sluggishness.  The  other  nervous  phenom- 
ena, which  are  usually  present  in  any  condition  when 
marked  typhoid  symptoms  exist,  are  not  prominent  in  this 
fever.  The  subsequent  phenomena  which  may  attend  its 
development  will  vary  with  the  intensity  of  the  fever  and 
the  resisting  power  of  the  patient. 

In  fatal  cases,  towards  the  close  of  the  second  week, 
symptoms  of  extreme  prostration  come  on,  the  piatient 
gradually  passes  into  a  state  of  stupor,  which  lapses  into 
one  of  coma,  and  death  ensues. 

In  cases  that  are  to  recover,  by  the  end  of  the  second 
week  the  tongue  begins  to  clean,  the  gastric  and  intestinal 
symptoms,  with  the  exception  of  the  diarrhoea,  begin  to 
subside,  the  pulse  becomes  slower,  the  nervous  disturbances 
disappear,  the  appetite  returns,  and  the  patient  enters  on  a 
convalescence  which  is  usually  protracted. 

It  is  apparent  that  the  early  stage  of  this  fever  very 
closely  resembles  that  of  simple  remittent,  while  its  latter 
stage  as  closely  resembles  that  of  typhoid. 

The  phenomena  of  both  stages  may  be  modified  by  cer- 
tain anti-hygienic  surroundings,  to  which  those  suffering 
with  this  fever  may  have  been  subjected  prior  to,  and 
during,  its  development.  Thus,  when  it  prevails  among 
those  who  have  suffered  privations,  been  badly  fed,  badly 


SYMTTOMS.  193 

clotlit'il,  ovorrrowdrd  in  )>a(lly  voiitilatrd  a])artinonts,  sur- 
roiiiult'd  by  (lt'C()in|>()siii<i:  animal  and  vrm'taMt*  snl>stanf<'S, 
altliou.u;!!  tin*  fever  is  ath'iidrd  l)y  I  lie  siime  <i;i'ni'ial  plienom- 
eiia  which  characterize  the  ty})h<)id  tyjx',  there  are  <:ert;iin 
variations  which  ally  it  to  relajtsiiiLi:  fever.  Proniinent 
anionu-  these  are  nenraluia.  and  arthrilic  ])ains  in  various 
])aits  of  thebody,  esi^'cially  in  the  back  and  limbs;  hemor- 
rhagic tendencies,  marked  by  l)leedin<j;s  from  the  o-ums, 
mucous  surfaces ;  and  not  unfrequently  large  eccliymoses 
occur  in  various  i)arts  of  the  body.  In  this  class  of  cases 
from  the  comniencemeut  the  fever  is  of  low  type,  with  quo- 
tidian excerbations  and  remissions.  Diarrhoea  usually  pre- 
cedes the  development  of  the  febrile  symi)tonis.  Frequently 
during  the  second  week  a  muttering  delirium  conies  on,  ac- 
companied by  drowsiness  and  a  tendency  to  stupor.  De- 
spondency, indis]iosition  to  make  any  exertion,  and  a  state 
of  utter  indifference  as  to  the  future,  is  frequently  met  with 
during  the  entire  period  of  the  fever. 

In  fatal  cases  death  may  be  the  result  of  hemorrhage 
from  the  mucous  surfaces,  or  from  exhaustion.  In  this 
class  of  cases  there  is  great  irritability  of  the  heart  and  a 
peculiar  mental  and  physical  prostration. 

In  cases  that  recover,  convalescence  comes  on  late,  and  is 
slow  and  tedious.  Diarrhoea  frequently  follows  the  subsi- 
dence of  the  fever,  which  in  many  cases  cannot  be  con- 
trolled, and  leads  to  a  fatal  result. 

The  complications  which  may  modify  the  course  of  any 
variety  of  typho-malarial  fever  are  very  similar  to  those 
which  are  met  with  in  tyi)ical  ty])hoid  fever.  Of  these  the 
most  frequent  is  inflammation  of  the  resjnratory  organs,  the 
development  of  which  is  marked  by  those  symptoms  which 
usually  attend  the  development  of  the  diffenMit  acute  jml- 
nionary  alTecti(»ns.  In  the  niajoiity  of  instances  the  signs 
of  bronchitis  are  not  present  until  the  fever  is  well  estab- 
lished. The  broncjiitis  resists  treatment,  and  does  not  dis- 
appear until  convalescence  is  fully  established.  When 
pneumonia  occurs  it  is  catairhal  in  chara.ctei-.  atid  few  of 
the  strongly  marked  rational  sym])tonis  of  ordinaiy  ])neu- 
monia  are  ])res«'nt.  Tjie  i)liysical  signs,  liowever,  will 
13 


194  TYPHO-MALAEIAL   FEVER. 

always  enable  you  to  determine  the  presence  of  pulmonary 
complications,  and  any  great  irregularity  in  temperature 
during  the  course  of  the  fever  should  lead  you  to  make  a 
careful  physical  examination  of  the  chest. 

It  is  sometimes  difficult  to  distinguish  between  the  cere- 
bral symptoms  of  this  fever  and  those  symptoms  which 
attend  meningeal  complications,  but  the  meningeal  compli- 
cations are  of  so  very  rare  occurrence  that  it  is  safe  to 
assume  they  are  not  present  until  some  of  the  diagnostic 
symptoms  of  meningitis  occur. 

We  rarely  have  serious  abdominal  complications,  such 
as  intestinal  perforation,  peritonitis,  and  hemorrhage,  but 
when  they  do  occur  their  advent  is  marked  by  such  urgent 
symptoms  that  one  loses  sight  of  the  ordinary  symptoms 
of  the  fever. 

It  is  hardly  necessary  for  me  to  refer  to  those  modifica- 
tions in  the  clinical  history  of  this  fever  which  follow  the 
development  of  abscesses,  bed-sores,  gangrene,  etc. 

Differential  Diagnosis. — The  affections  with  which 
typho-malarial  fever  are  likely  to  be  confounded  are  ty- 
phoid, remittent,  relapsing,  typhus,  and  yellow  fever. 

The  septic  type  of  typho-malarial  fever,  in  many  of  its 
phenomena,  so  closely  resembles  typhoid  fever  that  frequent- 
ly it  is  difficult  to  make  a  differential  diagnosis.  I  will 
briefly  state  the  points  of  difference  in  their  clinical  history. 

The  advent  of  typho-malarial  fever  is  usually  marked  by 
a  distinct  chill,  while  typhoid  comes  on  insidiously,  and  is 
not  attended  by  a  distinct  chill,  but  by  a  chilly  sensation. 
The  rise  of  temperature  in  typho-malarial  fever  is  sudden 
and  follows  no  typical  range,  while  in  typhoid  the  typical 
range  of  temperature  during  the  first  week  is  almost  diag- 
nostic of  the  fever. 

In  typhoid  fever,  on  the  sixth  or  eighth  day,  rose-colored 
spots  appear  ;  these  are  a  distinctive  mark  between  it  and 
typho-malarial  fever.  Although  in  the  latter  an  eruption 
may  be  present,  yet  it  has  none  of  the  characteristics  of  tlie 
typhoid  eruption,  is  not  rose-colored,  does  not  disappear  on 
pressure,  and  remains  visible  throughout  the  whole  course 
of  the  fever. 


DirFKlMCXTIAL  i)rA(;xosis.  105 

Besides  tlie  absence  of  tli.si'  cliarMcteristic  symptoms  of 
tyi)li()iil  fever,  in  typho  Mi;il:uial  fever  we  liave  a  distinct 
])('riodieity  in  the  f('l)rile  action,  a  certain  icteroid  luu;  of 
the  skin,  liepalic  tenderness,  extensive  splenic  enkirgement, 
and  ii:reat  gastric  disturbance  ;  conjoined  witli  these  t]ut 
ai)]iearance  of  tlie  tongue,  tlie  cliaracter  of  tli(;  diarrlicea, 
and  tlie  non-infectious  character  of  the  stools  in  ly]»ho- 
malarial  fever  s«n*ve  as  important  aids  in  the  diirercntial 
diagnosis  of  these  two  forms  of  fever.  In  typho-mahirial 
fever,  ui)()n  microscopical  examination  of  the  blood,  we  find 
free  i)igment  ;  this  is  never  or  rarely  found  in  the  blood  in 
typhoid  fever. 

The  malarial  type  of  typho-malarial  fever  resembles  re- 
mittent fever  in  its  ushering-in  symptoms.  In  both  cases 
there  is  a  chill  followed  by  fever,  attended  by  one  or  more 
distinct  exacerbations  and  remissions.  The  early  appear- 
ance of  the  enteric  symptoms,  attended  by  other  well- 
marked  typhoid  phenomena  by  the  end  of  the  second  week, 
establishes  the  diagnosis  of  this  type  of  malarial  fever,  and 
as  the  fever  progresses  the  typhoid  condition  becomes  more 
and  more  apparent.  Besides,  remittent  fever  yields  more 
promptly  to  the  use  of  quinine  than  does  typho-malarial 
fever. 

Severe  cases  of  typho-malarial  fever,  which  are  compli- 
cated by  scorbutic  tendencies,  marked  by  petechife  and 
great  prostration  of  the  vital  powers,  may  be  confounded 
with  typhus  fever ;  yet  the  severity  of  the  attack,  the 
higher  range  of  temperature,  the  greater  frequency  of  the 
pulse,  the  dusky  countenance,  the  absence  of  dian-hnea  and 
all  other  abdominal  symptoms  in  typhus  fever,  renders  it 
easy  to  make  the  differential  diagnosis  between  the  two 
types  of  fever.  Besides,  typhus  fever  has  a  characteristic 
eruption,  is  only  pro]iagated  by  contagion,  and  if  it  pre- 
vails, does  so  epidemically.  Occasionally  yellow  fev»M-  has 
been  confounded  with  typho-malarial  fever,  and  on  this 
account  I  will  mention  some  of  the  prominent  diagnostic 
sym])toms  of  yellow  fever  which  distinguisli  it  from  tyi)lio- 
malarial  fever. 

The   range  of   temperature   is   lower  in    f/dlow  than   in 


196  TYPHO-MALARIAL   FEVER. 

typho-malarial  fever,  and  on  the  third  or  fourth  day  it  falls 
suddenly,  and  there  is  more  or  less  complete  remission. 
The  circumorbital  pain,  the  appearance  of  the  eye,  the 
peculiar  color  of  the  skin,  the  character  of  the  matter 
vomited,  the  absence  of  diarrhoea,  the  presence  of  albumen 
in  the  urine,  and  the  shorter  duration  of  the  disease,  will 
enable  you  to  make  the  diagnosis  of  yellow  fever.  Again, 
yellow  fever  usually  prevails  epidemically,  and  is  confined 
to  certain  localities  and  certain  seasons  of  the  year.  It  is  a 
portable  disease,  and  the  yellow  fever  poison  may  be  con- 
veyed from  an  infected  to  a  non-infected  district  by  means 
of  clothing  or  merchandise,  while  the  poison  of  the  typho- 
malarial  fever  is  of  endemic  origin,  and  cannot  be  carried 
beyond  the  infected  district. 

The  points  of  differential  diagnosis  between  tyj)ho-mala- 
rial  and  relapsing  fever  will  be  considered  under  the  head 
of  relapsing  fever. 

The  differential  diagnosis  between  cerebro -spinal  menin- 
gitis and  typho-malarial  fever  is  sometimes  attended  with 
great  difficulty. 

Progistosis. — The  ratio  of  mortality  in  typho-malarial 
fever  varies  greatly  in  the  different  regions  in  which  it 
occurs,  and  as  the  malarial  or  septic  element  predominates. 
Tiie  hygienic  surroundings  of  the  patient  and  the  range 
of  atmospheric  temperature  will  also  very  greatly  influ- 
ence your  prognosis.  Statistics  of  this  fever  in  different 
localities  and  in  different  years  give  the  ratio  of  mortality 
from  one  in  twelve  to  one  in  twenty-four.  The  septic  type 
is  more  fatal  than  the  malarial  type.  Great  caution  should 
be  exercised  in  prognosticating  the  result  of  any  case,  for 
the  apparently  mildest  cases  sometimes  suddenly  assume 
a  severe  type  and  terminate  fatally,  while  very  severe 
and  apparently  hopeless  cases  unexpectedly  improve,  and 
recovery  takes  place. 

The  average  duration  of  those  cases  which  terminate  in 
recovery  is  from  three  to  four  weeks  ;  the  duration  varies 
with  tlie  different  types  of  the  fever.  In  the  malarial 
variety  the  duration  is  always  shorter  than  in  the  septic. 
The  period  of  convalescence  is  prolonged  ;   three  or  four 


I 


PROGNOSIS.  1 07 

weeks  often  elapse  brfoic  tlic  jiatiriit  is  completely  restored 
to  lu'alth.  A  fatal  relapse  may  occur  at  any  ])erio(l  dmiiiiz; 
convalescence.  In  those  cases  that  terminate  fatally,  (h-ath 
most  fretpiently  occurs  diiriim'  the  second  or  thiid  \\»'ek  ;  it 
may  occur  as  late  as  the  chxse  of  the  sixtii  week. 

The  occurrence  of  any  of  the  com])lications  to  wjiich  1 
have  refeiied  ns  ])ossibly  taking  place  during  the  course  of 
this  fever  will  very  materially  inllueiice  the  ])rognosis  in  any 
given  case.  Cai)illary  bronchitis  and  })neumonia  are  es- 
pecially dangerous  when  they  develop  during  the  third 
week  of  the  fever. 

Antidiygienic  surroundings,  such  as  overcrowding  and 
improper  food,  materially  affect  the  prognosis.  If  typho- 
nialarial  fever  prevails  among  thos(»  who  are  crowded  into 
badly-ventilated  apartments,  who  from  liltii  and  imjnopc^r 
nutrition  have  septic  and  scorbutic  tendencies,  the  ratio  of 
mortality  is  much  greater  than  among  those  wdio  are  free 
from  such  complicating  influences. 

The  symptoms  wdiich  may  be  regarded  as  indicating  an 
unfavoralile  termination  are  :  a  continued  liigh  tem})erature, 
showing  little  or  no  tendency  to  remission  ;  a  very  frequent, 
feeble,  fluttering  pulse ;  profuse  diarrha?a,  the  discharges 
at  times  being  involuntar}'  and  containing  mucus,  pus,  and 
blood ;  a  dry,  red,  cracked  and  fissured  tongue  ;  great 
drowsiness,  with  a  tendency  to  stupor  and  coma,  and  the 
appearance  of  petechial  spots  on  the  surface  of  the  bod}', 
attended  by  frequent  hemorrhages  from  the  lips,  gums,  and 
tongue.  In  a  severe  case,  the  occurrence  of  any  of  these 
comi)lications  renders  the  prognosis  more  unfavorable. 
The  character  of  the  prevailing  fever  will  also  greatly  influ- 
ence the  prognosis  in  any  given  case.  If  the  tyj)e  of  the 
prevailing  fever  is  mild,  or  if  comparatively  few  deaths 
have  occurred,  though  the  symptoms  in  a  given  case*  may 
appear  unfavorable,  yet  recover}-  is  probable.  If,  on  the 
other  hand,  the  type  is  severe,  and  many  deaths  have  oc- 
curred, apparently  mild  cases  will  suddenly  become  severe, 
and  the  prognosis  l)ecomes  unfavorabh'. 

As  I  have  already  stated,  the  hygienic  surroundings  and 
the  previous  habits  of  the  ]iatient  very  greatly  influence  the 


198  TYPHO-MALARIAL   FEVER. 

prognosis.    With  drunkards,  and  those  enervated  by  vicious 
habits,  a  mild  type  of  this  fever  will  probably  prove  fatal. 

Treatment. — The  treatment  of  typho-malarial  fever  va- 
ries with  its  type.  No  plan  can  be  presented  which  will  be 
applicable  to  all  cases. 

As  in  other  forms  of  disease,  the  first  question  that  meets 
us  under  the  head  of  treatment  is,  cannot  the  development 
of  this  fever  be  prevented  ?  While  speaking  of  its  etiology, 
I  stated  that  its  development  was  principally  due  to  three 
causes — namely,  malarial  poison,  overcrowding,  and  im- 
proper diet.  In  a  large  proportion  of  instances  it  is  possible 
to  do  away  with  the  last  two  causes.  The  overcrowding 
and  the  faulty  diet  may  be  prevented,  and  thus  the  septic 
poison  which  gives  to  this  fever  its  typhoid  type  may  be 
destroyed  or  its  development  prevented.  The  strict  ob- 
servance of  hygienic  laws  in  the  localities  where  this  fever 
prevails  has  in  some  instances  entirely  changed  the  type  of 
the  disease.  Even  after  the  fever  symptoms  have  been  well 
developed,  the  removal  of  patients  from  anti-hygienic  sur- 
roundings has  frequently  been  attended  by  the  most  satis- 
factory results.  When  isolated  cases  of  this  fever  are  met 
with  in  localities  apparently  free  from  such  sources  of  infec- 
tion, a  careful  search  should  be  instituted,  in  order  to  find 
the  source  of  the  infection.  Defective  sewerage  and  faulty 
drainage  have  been  found  to  be  fruitful  sources  of  infection. 

The  therapeutic  measures  which  may  be  employed  in  the 
treatment  of  this  form  of  fever  vary  with  the  type  of  fever 
and  the  peculiarities  of  each  individual  case.  There  are  no 
specifics. 

In  those  cases  in  which  the  malarial  element  predomi- 
nates, the  administration  of  quinine  as  an  antiperiodic  will 
produce  the  desired  result,  and  in  many  instances  arrest  the 
progress  or  shorten  the  duration  of  the  fever  ;  but  in  those 
cases  in  which  the  septic  element  predominates,  while  qui- 
nine may  act  as  an  antipyretic  in  the  same  way  as  it  does 
in  typhoid  fever,  it  has  little  power  to  arrest  the  progress 
or  shorten  the  duration  of  the  fever,  but  it  will,  in  most  in- 
stances, render  the  course  of  the  fever  milder. 

In   those  cases  in  which  the  malarial  element  predomi- 


TKKATMKNT.  100 

nates,  wlildi  are  ushered  in  by  distinct  cliills,  followed  by 
one  or  two  distinct  remissions  and  exacerbations,  durin.i,^  the 
first  rnnission  twenty  or  thirty  ^n-ains  of  quinine,  in  two  or 
three  doses  of  ten  grains  eacli,  should  be  administered  every 
hour  until  thr  desired  quantity  has  been  given.  If  it  is 
promptly  and  freely  adininistert'd,  it  seldom  fails  to  produce 
a,  beneticial  effect ;  usually  the  febrile  exacerbations  will 
not  return,  or  if  they  do  tluy  aic  less  severe,  and  in  a  few 
days  entirely  disappear. 

In  those  cases  which  begin  more  insidiously  and  are  de- 
veloi)ed  more  gi'adually,  if  there  is  a  distinct  periodicity  to 
the  febrile  phenomena,  without  distinct  remission,  although, 
by  the  administration  of  quinine,  you  may  not  shorten  the 
duration  of  the  disease,  yet  the  fever  will  run  a  moditled 
and  very  much  milder  course. 

If  the  first  full  doses  of  quinine  fail  to  produce  any  effect 
in  this  class  of  cases,  its  administration  in  moderate  doses, 
perhaps  ten  grains  twice  a  day,  must  be  continued  for  seve- 
ral days  before  it  will  markedly  modify  the  severity  of  the 
fever.  In  no  type  of  the  fever  does  the  quinine  exert  any 
specific  influence  except  over  the  malarial  element ;  the  en- 
teric phenomena  are  either  not  at  all,  or  only  indirectly, 
modified  by  the  antipyretic  power  of  the  drug.  Hence,  it  is 
apparent  that  in  those  cases  in  which  the  malarial  element 
is  slight,  ;ind  in  which  the  septic  element  is  prominent, 
while  quinine  fails  to  exercise  any  controlling  influence  over 
the  progress  of  the  fever,  it  will  mitigate  its  severity,  and 
act  more  powerfully  as  an  antipyretic  than  it  will  in  any 
other  form  of  continued  fever. 

It  has  been  claimed  by  some  that  arsenic  has  a  specific 
influence  over  typho-malarial  fever,  and  that  it  exercises 
a  peculiar  and  most  beneticial  effect  upon  the  intestinal 
lesions,  materially  shortening  the  duration  of  the  fever. 
There  is  little  doubt  but  that  arsenic,  like  quinine,  acts  be- 
neficially in  many  cases  of  the  malarial  type  of  this  fever ; 
but  unquestionably  this  beneticial  effect  is  due  to  its  ac- 
knowletlged  p(nver  over  malarial  affections,  and  not  to  any 
specihc  influeuce  which  it  has  over  the  fever.  As  an  anti- 
periodic  it  is  inferior  to  (quinine. 


200  TYPIIO-MALAKIAL  FEVER. 

The  antipyretic  treatment  of  typlio-malarial  fever  does 
not  materially  differ  from  that  recommended  for  the  reduc- 
tion of  temperature  in  typhoid  fever.  It  is  of  importance 
to  remember  that  this  class  of  patients  do  not  bear  well  the 
prolonged  application  of  cold  to  the  surface,  either  by 
means  of  the  cold  bath  or  the  cold  pack,  and  that,  unless 
the  antipyretic  power  of  quinine  is  added  to  the  application 
of  cold,  very  little  benefit  will  be  obtained  from  its  employ- 
ment. The  danger  resulting  from  the  injudicious  use  of 
cold  baths  is  greater  in  this  than  in  any  other  infectious 
disease. 

The  rules  for  the  administration  of  stimulants  in  typho- 
malarial  fever  are  the  same  as  those  given  for  their  adminis- 
tration in  typhoid  fever.     The  effects  of  the  first  few  doses 
should  be  carefully  watched.     They  should  never  be  given 
indiscriminately,  for  there  is  greater  danger  of  over-stimu- 
lating in  this  than  in  any  other  fever.     Their  use  is  indi- 
cated whenever  signs  of  heart-failure  are  present,  such  as  a 
feeble  pulse  and  an  indistinct  first  sound  of  the  heart.     No 
fixed  rule  can  be  laid  down  as  regards  the  quantity  to  be 
administered  in  any  given  case ;  it  will  vary  with  the  type 
of  the  fever  and  the  previous  habits  of  the  patient ;  it  should 
always  be  administered  at  stated  intervals.      The  period 
of  the  fever  at  which  stimulants  should  be  commenced  will 
also  vary.     In  some  cases,  stimulants  are  never  required, 
while  in  other  cases,  from   the  very  outset  of  the  fever, 
they  are  demanded.      In   the  majority  of  cases  their  use 
is  not  indicated  before  the  end  of  the  second  week.      It 
must  be  borne  in  mind  that  alcohol  is  not  a  specific,  cura- 
tive agent  in  this  fever,  but  that  the  object  of  its  adminis- 
tration is  to  sustain  the  heart  and  prevent  the  vital  powers 
from  falling  below  the  point  at  which  reparative  processes 
are  possible.     The  use  of  stimulants  is  not  necessarily  con- 
tra-indicated when  delirium  is  present.     Frequently  after 
their  administration  the  delirium  will  pass  away,  and  only 
when  it  is  decidedly  increased  by  their  use  should  they  be 
abandoned. 

The  state  of  the  bowels,  skin,  and  kidneys  demands  the 
closest  attention.     If,  early  in  the  disease,  the  bowels  are 


TREATMENT.  201 

constipated,  a  calomel  purge  coinbined  with  ten  oi*  fifteen 
grains  of  quinine  will  often  be  followed  by  marked  ben<'lit. 
In  any  stage  of  the  disease  brisk,  purgation  should  be 
avoided.  If  diarrhoea  is  present,  it  should  not  be  inter- 
fered with  unless  it  becomes  exhausting ;  then  it  should 
be  checked  by  small  doses  of  oi)ium  combined  with 
astringents. 

When  the  skin  l)ecomes  dry  and  parched,  if  cold  baths  or 
packs  are  not  admissible,  the  surface  should  frequently  be 
sponged  with  tepid  water.  It  has  been  proposed  by  some 
to  apply  oil  to  the  surface  two  or  three  times  every  day, 
when,  from  extreme  exhaustion  or  any  other  cause,  bath- 
ing or  sponging  of  the  surface  cannot  be  practised. 

Special  notice  should  be  taken  of  the  quantity  and 
character  of  the  urine.  If  it  becomes  scanty  and  high- 
colored,  or  if  there  is  a  temporary  suppression,  it  is  of 
the  utmost  importance  that  the  functions  of  the  kidneys 
should  be  immediately  restored.  This  can  be  best  accom- 
plished by  the  administration  of  digitalis  combined  with 
spirits  of  nitre.  Sometimes  retention  may  be  mistaken  for 
suppression  of  urine,  unless  a  careful  examination  be  made 
as  to  the  condition  of  the  bladder.  Symptoms  referable  to 
disturbance  of  the  nervous  system  sometimes  require  special 
treatment.  If  there  is  extreme  restlessness,  muscular  twitch- 
ings,  or  active  delirium,  opium  may  be  administered  in  full 
doses.  The  effect  of  the  first  dose  must  be  carefully 
watched.  If  sleep  soon  follows  its  administration,  and  the 
delirium  gmdually  subsides  without  any  aggravation  of  the 
other  symptoms,  its  use  may  be  continued  ;  if,  instead  of 
producing  sleep,  the  patient  becomes  more  wakeful,  and 
the  delirium  is  increased  and  more  active,  and  the  other 
symptoms  are  greatl}'  aggravated,  its  use  must  be  imme- 
diately abandoned.  Under  these  circumstances  chloral 
may  be  tried  with  great  care. 

Some  claim  that  spirits  of  turpentine  in  the  treatment  of 
this  form  of  fever  has  almost  a  specific  ]iower,  while  others 
regard  it  useful  only  as  a  stimulant.  My  own  exp«*rience 
leads  me  to  employ  it  only  as  a  stimulant  during  the  second 
and  third  weeiv  of  the  disease,  when  there  is  great  prostra- 


202  TYPIIO-MALARIAL   FEVER. 

tioii  and  marked  typhoid  s3''mptoms.  It  may  be  given  as 
an  emulsion  in  doses  of  twenty  drops  every  two  hours. 

The  diet  best  suited  to  patients  witli  this  fever  is  milk 
administered  in  the  same  way  as  was  proposed  in  the  case 
of  typhoid  fever  patients. 

Special  complications  occurring  during  typho-malarial 
fever  must  be  met  with  such  remedies  as  the  condition 
of  the  patient  and  the  peculiar  complications  may  require. 


CONTAGIOUS    FEVERS. 


LECTURE  XVIII. 


TYPHUS  FEVER. 
Introduction. — Morbid  Anatomy. — Etiology. 

At  my  last  lecture  I  completed  the  history  of  malarial 
fevers. 

I  will  now  commence  the  history  of  the  contagloufffepers; 
and  the  tirst  which  will  engage  our  attention  in  tliis  class 
is  t}^3hus  fever.  This  fever,  like  those  which  we  have 
just  been  considering,  depends  upon  changes  produced  in 
the  blood  by  a  morbific  agent  developed  exterior  to  the 
body. 

Although  it  has  many  phenomena  in  common  with  the 
miasmatic  contagious  fevers,  and  has  until  quite  recently 
been  classed  with  typhoid  fever,  yet  with  our  present  knowl- 
edge it  must  be  regarded  as  a  distinct  type  of  fever,  de- 
pendent upon  a  specific  poison,  with  certain  pathological 
and  etiological  i)henomena  which  distinguish  it  from  all 
other  forms  of  disease. 

Typhus  fever  is  an  epidemic  disease.  It  has  received  a 
great  variety  of  names,  such  as  ^^  shlp-fecer,'^  ^' Jiospltal 
fevery^'  ^'Jail-fever,'''  '^  ca?tip -fever,''  '"'- peteclilal  fever,'" 
"-  putrid  fever,"  '' continued  fever,"  and  typhus  fever.  Tiie 
Gernums  describe  an  ahdomlnal  and  cerchral  ty])hus.  Their 
abdominal  tyiilius  corresponds  to  our  typhoid  fever,  and 
tht'ir  cerebral  ty])hus  is  our  ty])hus  fever. 

Mouiui)  Anatomy. — I  shall  liist  consider  those  patholo- 
gical lesions  which  are  common  to  typhus  and  typlioid 
fever,  and  as  1  draw  the  line  of  distinction  between  them, 


206  TYPHUS   FEVER. 

you  will  notice  that  in  many  respects  tlie  difference  is  one 
of  degree  rather  than  of  kind. 

First,  I  will  speak  of  the  changes  in  the  blood. 

Blood. — The  blood  in  typhus  fever  is  darker  in  color  than 
normal,  and  when  drawn  from  the  body  during  life  coagu- 
lates imperfectly  or  not  at  all ;  if  a  clot  is  formed,  it  is  of 
tlie  consistency  of  putty.  The  fibrin  is  diminished,  or  to  a 
greater  or  less  extent  loses  its  coagulating  power.  At  first 
the  red  globules  are  increased  in  number,  but  as  the  disease 
progresses  they  diminish  in  number,  the  salts  of  the  blood 
are  also  changed,  and  urea  and  ammonia  are  present  in 
excess  ;  b.y  some  the  latter  is  supposed  to  be  produced  by 
the  decomposition  of  the  former.  The  blood  of  a  typhus 
fever  patient,  when  drawn  from  the  body,  rapidly  undergoes 
ammoniacal  decomposition.  When  the  blood  is  examined 
microscopically,  many  of  the  red  blood-globules  will  be 
seen  to  have  lost  their  normal  outline,  and  their  edges  to 
have  become  serrated  and  irregular.  In  some  instances 
they  will  be  found  to  have  undergone  degeneration ;  their 
coloring  matter  will  then  pass  through  the  walls  of  the 
blood-vessels  and  stain  more  or  less  deeply  the  tissues  and 
effusions  which  may  have  taken  place  in  the  serous  cavities. 
These  blood-changes  are  very  similar  to  those  which  take 
place  in  the  miasmatic  contagious  fevers — they  differ  rather 
in  degree  than  in  kind. 

Paeenchymatous  Degenerations. — There  is  the  same 
tendency  to  parenchymatous  degenerations  of  the  different 
organs  and  tissues  of  the  body  in  typhus  as  in  typhoid. 
Usually  the  body  is  not  very  much  emaciated  ;  it  under- 
goes decomposition  much  more  rapidly  after  death  from 
typhus  than  after  death  from  typhoid  fever.  In  severe 
cases  decomposition  apparentl}^  commences  before  death. 
The  muscles  are  usually  of  a  brownish  color,  drj^,  present- 
ing an  infiltration  of  fine  granules  in  the  primitive  fibres  ; 
sometimes  hemorrhages  take  place  into  them. 

The  liver  and  spleen  undergo  degenerative  changes  simi- 
lar to  those  described  as  occurring  in  typhoid,  but  they  are 
not  so  extensive  nor  are  they  so  constant.  You  may  make 
very  many  autopsies  on  persons  dying  of  typhus  fever, 


:\roi;i;il)    ANATOMY.  207 

witliouf  fiiuliii,!::  niiy  softrTiiiii?  or  only  a  vory  moderate?  soft 
oniiiir  of  th<'  s]>l»'<Mi.  Tin*  ]);in'nchyinatous  clianges  in  tlie 
kidiit'vs  :nr  !iiui-li  nioiv  <'xtt'nsiv('  and  constant  in  typlnis 
than  in  tvi>lu>i<l.  In  scvon'  cases  the  cortical  ])ortion  of  the 
organs  is  swoll.-n,  opaqne,  and  more  or  h^ss  fatty,  according 
to  the  duration  and  severity  of  the  disease.  Tlie  ])rimary 
enlargement  of  tht»  kidneys  is  mainly  due  to  a  cloudy  swell- 
ing of  the  epithelium  of  the  renal  tubes. 

This  tendency  to  cloud}-  swelling  and  granular  fatty  de- 
g(Mieration,  which  occurs  in  the  voluntary  muscles  and  the 
kidneys,  also  occurs  in  the  muscular  tissues  of  the  heart. 
If  the  fever  is  protracted,  the  cardiac  walls  become  flaccid, 
of  a  brownish  color,  and  parenchymatous  changes  are  found 
similar  to  those  which  occur  in  typhoid  fever,  though  less 
mark<'d.  There  is  often  a  considerable  amount  of  serum  in 
the  pericardium.  Pultaceous  clots  are  found  in  the  heart 
cavities,  and  thrombi  are  found  firmly  adherent  to  the  walls 
of  the  larger  veins. 

There  is  the  same  tendency  to  ulceration  of  the  mucous 
membrane  of  the  mouth  and  larynx  as  in  typhoid  fever.  In 
typhus  fever  the  ulcers  are  deeper,  involving  more  exten- 
sively the  submucous  tissue. 

Splenization  of  the  lungs  also  occurs  in  typhus  as  in  ty- 
phoid fever. 

Thus  far  we  have  only  noticed  those  lesions  which  occur 
both  in  ty]ihus  and  in  typhoid  fever.  We  now  come  to 
those  which  are  found  only  in  typhus. 

BijAi.v. — Although  tliere  is  nothing  in  the  appearance  of 
the  brain  which  is  characteristic  of  this  fever,  yet  it  is  very 
unlike  that  met  with  in  typhoid  fever.  In  the  latter  dis- 
ease it  usually  presents  an  anajmic  appearance.  In  all  cases 
of  typhus  the  cerebral  vessels  will  be  found  more  or  less 
congested. 

In  some  epidemics  you  will  find  all  the  sinuses  and  blood- 
vessels of  the  brain  engorged  witli  dark  blood,  so  that  when 
the  calvaiia  is  removed  the  vessels  will  stand  out  upon  the 
surface  of  the  brain.  In  other  epidemics,  instead  of  finding 
intense  congestion,  there  will  be  a  more  or  less  extensive 
serous  effusion  into  the  meshes  of  the  pia  mater  ;  the  quan- 


208  TYPHUS    FEVER. 

tity  of  the  elTiision  varies  from  one  to  eight  or  ten  ounces, 
aiul  it  is  most  abundant  upon  the  convex  surface  of  the 
brain,  altliough  it  also  takes  place  to  a  limited  extent  into 
tlie  ventricles.  Wherever  there  is  a  large  amount  of  fluid 
effusion  there  will  be  little  cerebral  congestion.  The  fluid 
effusion  is  usually  clear  ;  it  may  be  turbid,  and  when  it  is  so 
you  may  be  certain  that  the  fever  is  complicated  by  menin- 
gitis. The  arachnoid  loses  its  natural,  glistening  appear- 
ance, and  in  many  instances  you  will  find  the  membrane 
dotted  over  with  yellow  or  3^ ello wish- white  spots. 

The  brain  undergoes  little  or  no  change  unless  the  fluid 
effusion  is  abundant,  when  by  its  pressure  the  sulci  are 
deepened  and  the  convolutions  are  sharpened. 

It  will  be  seen  that  instead  of  having  little  or  no  serous 
effusion  in  the  cranial  cavity,  as  is  the  case  in  typhoid 
fever,  there  is  either  an  intense  congestion  of  the  cerebral 
vessels,  or  an  abundant  fluid  effusion  underneath  the  arach- 
noid and  into  the  cavities  of  the  ventricles.  In  this  regard 
there  is  a  marked  difference  in  the  appearance  of  the  brain 
in  these  two  forms  of  fever. 

Abdominal  LESioivrs. — In  typhus  and  typhoid  fever,  the 
lesions  found  in  the  abdominal  cavity  widely  differ.  The 
veal  pathological  distinction  is  in  the  presence  or  absence  of 
intestinal  changes.  These  are  present  in  typhoid  and  absent 
in  typhus. 

In  typhus  fever  there  are  no  changes  which  show  a  ten- 
dency to  ulceration  of  the  intestinal  glands,  except  those 
which  are  produced  by  congestion,  such  as  is  frequently  seen 
in  scarlet  fever  and  measles,  that  is,  the  Pe3^erian  patches 
present  the  shaven -beard  a^^pearance  ;  while  in  typhoid 
fever,  either  ulceration  of  the  intestinal  glands  will  be  pres- 
ent, or  the  glands  vvill  pi-esent  the  appearance  which  just 
precedes  ulceration.  At  the  post-mortem  examination,  if 
ulceration  of  the  agminated  and  solitary  glands  is  found, 
we  may  be  certain  the  patient  died  of  typhoid  fever.  In 
typhus  fever  there  is  no  enlargement  of  the  mesenteric 
glands,  which  in  typhoid  fever  is  usually  present. 

The  presence  or  absence  of  intestinal  changes  settles  the 
question,  is  the  fever  typhus  or  typhoid  i 


:\I<)Kr.Il)    ANATOMV.  209 

Comj)Ifcrrfions'. —Wthimixh  tlw  (•<)in])licali<>Ms  wliicli  occur 
in  the  course  of  ty])!ius  fever  an*  iu  no  way  peculiar  to  it, 
yet  they  are  of  such  frec^uent  occurrence,  and  are  devel- 
oped durinii:  it^  active  progress  and  modify  its  pheno- 
mena to  such  a  (h'gre.'.  that  it  is  necessary  that  tliey  should 
be  taken  into  account  in  the  study  of  its  pathoh)gical 
lesions.  You  will  rarely  make  a  post-mortem  u])on  one 
who  has  died  from  this  disease  without  linding  the  evidence 
of  some  complication  that  has  occunvd  dui-ing  tlie  progress 
of  the  fever.  These  coin])licati()ns  will  vary  according  to 
tile  peculiar  type  of  the  eiiidemic  which  is  pnn-ailing  at  tlie 
time  the  death  occurred.  In  one  epidemic  the  complica- 
tions will  be  pulmonar\',  in  another  they  will  be  almost  ex- 
clusively cerebral  and  spinal,  in  another  nearly  all  will  be 
glandular  in  character. 

The  pulmonary  complications  are  bronchitis,  pneumonia, 
pleurisy,  pulmonary  congestion,  and  oedema.  In  most 
cases  these  pulmonary  complications  are  developed  during 
the  primary  fever,  before  convalescence  commences. 

Their  advent  is  always  insidious.  You  may  have  an  ex- 
tensive capillary  bronchitis  develop  with  very  few  of  the 
rational  symptoms  of  bronchitis  present  until  within  a  very 
short  time  previous  to  the  death  of  the  patient ;  in  fact,  the 
bronchitis  might  pass  unrecognized  but  for  the  presence  of 
its  physical  signs. 

All  the  rational  symptoms  of  pneumonia  ma}^  also  l)e 
absent,  and  still  a  physical  examination  of  the  chest  may 
reveal  a  whole  lung  in  a  state  of  pneumonic  consolidation. 
Tlie  pneumonia  which  complicates  typhus  is  of  the  catarrhal 
variety.  It  often  leads  to  pulmonary  gangrene,  so  that 
gangrene  of  the  lung  in  connection  with  the  development  of 
typhus  is  not  of  infrequent  occurrence. 

Pleurisy  is  of  so  rare  occurrence  that  it  maybe  passed 
with  the  simple  statement  that  it  is  an  occasional  complica- 
tion, its  physical  signs  only  revealing  its  presence. 

At   most   of   the   autopsies  you   make   of   typhus   fever 

patients  you  will  find  there  has  been  pulmonary  congestion 

and   oedema.       In    many  cases,  when  it  is  associated  with 

cai)illarv  bronchitis  or  juieumonia,  it  is  the  immediate  cause 

14 


210  TYPHUS   FEVER. 

of  death,  and  great  care  should  be  taken  in  your  physical 
examinations  that  you  may  detect  its  commencing  develop- 
ment. 

Laryngitis  is  often  associated  with  the  more  extensive 
bronchitis  Mrhich  occurs  during  the  active  part  of  the  fever. 
The  only  cerebro-spinal  complication  which  is  met  with  in 
typhus  fever  is  meningeal  inflammation. 

As  I  have  stated,  in  a  large  majority  of  autopsies  of  ty- 
phus fever  you  will  find  serum  in  the  meshes  of  the  pia 
mater,  but  that  is  not  a  certain  sign  that  meningeal  inflam- 
mation has  existed  prior  to  death.  In  addition  to  the  sub- 
arachnoid effusion,  there  must  be  an  exudation  of  plastic 
material ;  the  arachnoid  must  have  lost  its  shining  appear- 
ance, and  be  thicker  than  normal.  When  such  appearances 
are  found  it  shows  that  the  case  has  been  complicated  by 
meningitis.  The  development  of  delirium  and  active  cere- 
bral symptoms  is  not  positive  evidence  that  the  patient  is 
suffering  from  meningeal  complication,  for  the  delirium  and 
cerebral  excitement  may  occur  independently  of  meningitis. 
It  is  by  the  character  of  the  delirium,  and  by  the  change 
in  the  pulse  and  the  appearance  of  the  pupils,  that  this 
complication  is  recognized. 

Glanclnlar  Enlargements.— 'Y\\q  glandular  enlargements 
and  inflammations  which  occur  in  the  course  of  typhus 
fever  are  peculiar  in  their  character,  and  are  rarely  met 
with  in  typhoid,  and  then  are  not  extensive  ;  but  in  typhus 
fever  the  external  glands  of  the  body— especially  those 
about  the  neck,  the  parotid  and  sublingual— of  ten  become  so 
much  enlarged  and  inflamed  as  to  interfere  with  deglutition, 
and  not  infrequently^  these  glandular  enlargements  are  ap- 
parently the  immediate  cause  of  death. 

The  inguinal  glands  sometimes  become  so  enlarged  as 
to  interfere  with  the  return  circulation,  and,  as  the  con- 
sequence of  this  interference,  swelling  of  \\\^  lower  extremi- 
ties may  be  developed.  There  is  a  swelling  of  the  lower 
extremities  which  depends  upon  a  different  cause.  It  may 
occur  at  the  beginning  of  convalescence  ;  then  the  limbs 
will  present  very  nearly  the  same  appearance  as  that  notice- 
able in  the  condition  ciAlQx}.  2)Jilegmasia  dolens.   Under  such 


ETIOLOGY.  211 

circunistniicfs  you  iikiv  lliiiik  iIk-  ]);iticiil  lins  jililrhii  is. 
\()ii  will  nTollt'cl  llial  1  linvc  slated  lo  ^ou  lliat  the  volun- 
tary niusclcs  undergo  (Ic.ucncialioii,  and  that  the  same  kind 
of  def^eneration  occurs  in  the  luuscular  tissue  ol'  the  heaii. 
AVhen  this  does  occur  the  walls  oL'  the  heart:  become  veiy 
tkil)by,  and  when  this  chan^ue  has  reached  a  certain  ])oint 
there  is  developed  a  tendency  to  the  formation  of  cjols  in 
tlie  heart  cavities,  and  a  slowini;"  of  th(^  general  circulation. 
The  result  of  such  retarding  or  obstruction  of  the  return 
circulation  is  the  formation  of  thrombi  in  tlu?  superficial 
veins,  which  interfere  with  the'  return  circulation,  and  a 
swelling  of  the  lower  extremities  follows  ;  this  closely  re- 
sembles that  which  is  seen  in  phlegmasia  dolens.  AVith 
this  swelling  of  the  lower  extremities,  su])])uration  and  cel- 
lular inllammation  may  occur,  which  often  results  in  the 
fornuition  of  quite  extensive  abscesses. 

It  is  an  established  fact  that  whenever  the  return  circula 
tion  is  slowed  from  any  cause  in  any  disease  where  there  is 
great  feebleness  of  heart  power,  very  frequently  thrombi 
form  in  the  veins  of  the  lower  extremities.  This  is  often 
well  illustrated  in  the  latter  stages  of  phthisis,  when  swell- 
ing of  one  or  both  lower  extremities  occurs  as  the  result  of 
the  formation  of  venous  thrombi  in  the  superficial  veins. 

Di.'^icases  of  the  organs  of  the  special  senses,  which  so 
frequently  complicate  typhoid,  rarely  occur  in  typhus 
fever,  and  there  are  no  serious  or  constant  conqjlications  of 
the  digestive  organs. 

We  have  now  noticeil  the  moi-e  jirominent  lesions  of 
typhus  fever,  aiul  although  tin'i-e  an;  none  which  can  be 
regarded  as  characteristic,  still  they  widely  dilf(M-  from 
those  of  any  other  form  of  fever,  and  more  especially  from 
those  of  tj'phoid. 

Enor.oGY. — I  now  pass  from  the  study  of  the  pathologi- 
cal lesions  of  typhus  fever  to  its  etiology.  At  the  i)resent 
day  this  fever  is  regarded  as  depending  upon  a  specific 
poison,  of  whose  exact  nature  we  are  ignorant.  All  ob- 
servers agree  that  in  the  majority,  if  not  in  all  instances,  it 
is  the  ])rodnct  of  co/i/'n/i'/n,  and  that  the  contagion  only 
emanates  from   the  bodies  of   those  who  are  alTected  with 


212  TYPHUS   FEVEE. 

the  fever.  More  recent  German  writers  state  tliat  tlie 
tj^plins  poison  is  a  germ  which  is  capable  of  indefinite  re- 
])roduction.  This  is  a  matter  of  theory,  and  not  fact,  for 
no  one  as  yet  has  been  able  to  determine  the  existence  of 
snch  germs  either  by  microscopical  or  chemical  research. 
Careful  clinical  observation  has  established  this  fact  beyond 
a  doubt :  that  there  exists  a  specific  typhus  poison,  which 
can  be  communicated  from  the  sick  to  the  healthy,  which 
some  declare  is  never  of  spontaneous  origin,  while  others 
maintain  that  the  poison  may  be  generated  "^e  novo.'''' 

Some  have  strenuously  maintained  that  it  can  be  devel- 
oped by  overcrowding  and  filth  ;  others,  who  have  seen  the 
largest  number  of  typhus  fever  cases  during  the  past  ten 
years,  maintain  that  at  least  it  is  very  doubtful  whether 
typhus  fever  is  ever  of  spontaneous  origin.  It  is  possible 
to  develop  a  fever  from  overcrowding,  imperfect  ventilation, 
filth,  and  a  combination  of  causes  belonging  to  this  cate- 
gory, but  such  an  one  is  a  septic  fever,  and  not  typhus 
fever. 

Some  observers  have  gone  so  far  as  to  express  the  opinion 
that  scarlet  fever  and  typhus  are  closely  allied  both  in  their 
etiology  and  morbid  anatomy,  and  that  typhus  fever  is  no 
more  likely  than  scarlet  fever  to  be  of  spontaneous  origin. 
Tlie  results  of  my  investigation  of  the  origin  of  the  epidemic 
of  typhus  fever  which  prevailed  in  this  city  from  July, 
1861  to  1861:,  have  led  me  to  the  belief  that  typhus  poison 
is  of  endemic  origin — in  other  words,  that  there  are  certain 
endemic  centres ;  that  Ireland,  Italy,  and  Russia  are  the 
great  centres,  and  that,  whenever  it  occurs  in  other  locali- 
ties, it  has  been  conveyed  from  these  endemic  centres  to 
those  localities. 

In  the  month  of  July,  1861,  in  one  day  fourteen  cases  of 
typhus  fever  were  admitted  to  the  fever  wards  of  Bellevue 
Hospital,  of  which  wards  I  had  the  charge.  Previous  to 
this  time,  for  several  years  (I  think  for  more  than  ten  years), 
there  had  been  no  case  of  typhus  fever  in  the  wards  of  the 
hospital.  Immediately  I  commenced  investigations  in 
order  to  ascertain  the  origin  of  the  fever  in  these  cases.  I 
found  that  the  fever  had  its  origin  in  the  upper  story  of  a 


KTIOLOGY.  213 

rear  teiKMuent-houso  in  Mulberry  Street,  in  tlie  most  lillliy 
portion  of  the  city.  The  tirst  case  was  that  of  a  little  girl, 
who  had  been  brought  into  the  house,  ten  days  before  she 
siekeued,  from  a  sliij)  wliicli  iiad  come  froni  Ireland,  and 
which  had  eases  of  Lyplius  fever  on  board.  Two  weeks 
after  her  illness  commenced,  her  aunt,  the  only  other  occu- 
pant of  the  apartments  (consisting  of  a  room  and  dark  bed- 
room), sickened  of  fever  and  died.  In  gradual  succession, 
nearly  every  family  residing  in  the  building  took  the  fever. 

Becoming  frightened,  some  of  these  families  moved  into 
other  streets,  formed  the  nucleus  for  the  development  of 
the  disease  in  the  dilferent  localities  to  which  th(^y  removed, 
and  it  soon  became  a  widespread  epidemic.  There  were 
two  hundred  typhus  fever  ])atients  at  one  time  in  the  hos- 
l)ital. 

These  families  were  as  well  nourished  and  lived  in  as  well 
ventilated  apartments  as  thousands  of  their  class  in  other 
parts  of  the  city.  The  only  difference  was  that  ty})hus 
poison  was  brought  to  them  in  the  person  of  the  little  girl, 
and,  on  account  of  their  badly  ventilated  apartments  and 
their  utter  disregard  of  all  hygienic  laws,  they  furnished  a 
fit  soil  for  the  rejjroduction  and  spread  of  that  tjphus 
poison,  the  constant  and  unrestrained  intercourse  between 
the  healthy  and  the  sick  being  the  means  b}'  which  the 
fever  was  spread. 

T  found  unmistakable  evidence  that  ])ersons  living  in 
healthy  localities,  simi)ly  by  visiting  friends  sick  with  the 
fever,  contracted  tlie  disease. 

The  histories  of  those  cases  which  were  developed  within 
the  limits  of  the  hosi)ital  showed  that  a  residence  in  an  at- 
mosphere necessarily  more  or  less  tainted  with  tyi)lius 
poison  is  not  sufhcient  to  develop  the  disease,  but  that  it 
is  necessary  for  the  subject  of  the  contagion  to  have  been 
brought  in  contact  with  an  infected  person,  or  within  the 
atmosi)here  immediately  imi»regnated  with  his  exhalations. 

The  fact  that  no  em))loyee  in  the  hos])ital,  who  was  only 
brought  in  contact  with  the  clothing  of  fever  i)atients,  con- 
tracted the  disease,  as  well  as  the  absence  of  any  evidence 
that  the  disease  was  ])roi)agated  by  such  clothing,  goes  far 


214  TYPHUS   FEVER. 

to  prove  that  typlius  fever  cannot  be  propagated  by  fomites 
alone.  The  certaint}^  with  which  every  unprotected  person 
who  was  brought  in  personal  contact  with  fever  patients 
contracted  the  disease,  proves  the  contagious  power  of  the 
poison. 

The  distance  that  typlius  poison  can  be  transmitted 
through  the  atmosphere  (from  the  manner  in  which  the 
disease  was  contracted  by  some  of  the  house  physicians), 
would  seem  to  be  limited.  It  has  been  proved  by  actual 
experiment  that  the  contagious  distance  of  small-pox,  in 
the  open  air,  does  not  exceed  two  and  one-half  feet,  and  it 
would  seem  that  the  contagious  distance  of  typhus  fever  is 
even  less  than  two  and  one-half  feet. 

The  question  now  arises,  can  this  poison  be  conveyed  in 
the  clothing  ? 

During  the  epidemic  to  which  I  have  referred,  when  ty- 
phus fever  patients  were  brought  into  the  hospital,  their 
clothing  was  removed  in  the  reception  room,  and  after- 
wards washed  and  packed  away  in  a  lower  room  of  the 
building.  Upon  a  most  thorough  investigation  made  at 
that  time,  I  found  that  not  a  single  person  contracted  the 
disease  whose  duty  it  was  to  wash  or  pack  away  the 
clothing ;  but  every  one  whose  duty  it  was  to  carry  the 
fever  patients  from  the  reception  room  to  the  hospital 
ward  took  the  fever.  Every  physician  and  nurse  who 
had  the  care  of  typhus  fever  patients  contracted  the 
disease  ;  those  who  were  on  the  surgical  service  escaped. 
Every  clergyman  who  came  to  administer  spiritual  conso- 
lation to  patients  in  the  fever  ward  fell  a  victim  to  the  dis- 
ease. I  have  brought  forward  these  facts  to  show  that 
during  this  epidemic  there  was  no  evidence  that  the  disease 
was  either  of  spontaneous  origin,  or  that  it  was  transmitted 
from  the  sick  to  the  healthy  except  by  direct  personal  con- 
tagion. 

Typhus  poison  is  undoubtedly  present  in  the  body  exha- 
lations and  the  expired  air  of  typhus  fever  patients  ;  but  it 
requires  a  concentration  of  the  poison  to  render  it  infec- 
tious. Slight  exposure  is  not  sufficient ;  it  requires  a  con- 
centrated poison  and  a  prolonged  exposure.     The  more  nu- 


ETIOLOGY.  215 

merous  tlif  tyi)lius  f.-vrr  patients  are,  tlie  more  powerful 
dors  the  eoiitai^ioii  becoiiit.'  ;  yet  a  siii.s;le  exposure  even  to 
SLK'li  an  atmosphere  is  rarely  siillieient  to  develop  the  dis- 
ease ill  ail  individual  who  is  in  good  liealth  at  the  time  of 
the  exjiosure. 

If  any  of  you  are  so  eircumstant-ed  as  to  be  obliged  to 
tak.'  I  lie  medical  eliarge  of  typhus  fever  i)atients,  you 
should  make  your  visits  as  slujrt  as  possible,  and  when  you 
are  about  to  auscultate  the  eliest  of  a  fever  ]nitient,  take  a 
full  inspiration  at  an  o])en  window,  and  hold  your  breath 
while  you  are  listening  to  the  respiratory  sounds,  never 
inhale  the  air  from  the  bed  of  the  patient  as  you  examine 
the  posterior  surface  of  the  chest.  As  a  rule,  make  your 
visits  short  to  a  typhus  fever  patient,  avoid  inhaling  the 
exhalations  of  the  body,  never  make  a  visit  until  after  eat- 
ing ;  if  you  observe  these  simple  directions,  you  will  in  the 
majority  of  instances  escape  contagion. 

The  length  of  the  period  of  incubation  varies.  For  the 
development  of  the  disease,  it  usually  requires  about  two 
weeks  of  exposure,  such  as  comes  to  one  who  is  around 
those  sick  with  the  fever.  Repeatedly  have  J  noticed  this 
fact  in  my  own  case.  I  have  never  had  typhus  fever,  and 
have  never  taken  sjjecial  care  to  avoid  infection.  My  im- 
munity is  probably  due  to  some  special  constitutional  idio- 
S3'ncrasy.  I  have  noticed  that  whenever  I  enter  upon  a 
typhus  fever  service,  I  do  not  experience  any  effects  from 
the  exposure  to  typhus  poison  until  about  two  weeks  has 
elapsed,  then  I  begin  to  suffer  from  a  peculiar  form  of  head- 
ache which  continues  for  about  two  weeks  ;  the  })eriod 
before  tlie  commencement  of  the  headache  corresponds  to 
the  period  of  incubtition,  and  the  period  of  headache  to  the 
average  duration  of  the  disease. 

At  the  present  day,  the  estaldished  belief  is  that  typhus 
fever  attacks  an  individual  but  once,  and  that  those  who 
have  had  typhoid  fever  are  to  a  certain  degree  protected 
from  typhus.  Of  all  the  typhus  fever  patients  treated  in 
Bellevue  Hospital,  only  three  gave  histories  of  having  ])re- 
viously  had  the  disease.  I  recall  the  case  of  a  nnin,  seri- 
ously ill,  who  was  treated  in  the  fever-tents  for  typhus  fever, 


216  TYPHUS   FEVEE. 

had  tlie  cliaracteristic  eruption,  left  the  fever-tents  well, 
and  in  three  weeks  returned  with  the  fever,  and  was  more 
seriously  ill  than  during  his  first  attack  of  the  disease. 

From  the  facts  which  I  have  brought  before  you,  we  must 
reach  the  following  conclusions  : 

First. — That  typhus  fever  is  due  to  a  specific  poison. 

Second. — That  this  poison  is  communicated  from  the  sick 
to  the  healthy  only  by  personal  contagion — that  is,  the 
recipient  of  the  poison  must  be  brought  in  contact  with 
the  personal  exhalations  of  the  infected  person. 

Tliird. — That  where  there  is  free  ventilation,  personal  con- 
tagion is  confined  to  narrow  limits. 

Fourth. — That  the  evidences  of  the  spontaneous  origin  of 
typhus  are  not  conclusive,  although  there  can  be  no  ques- 
tion but  that  overcrowding  and  bad  ventilation  favor  its 
spread  and  increase  its  severity. 

Fifth. — Typhus  poison  passes  into  the  body  mainly 
through  the  respired  air.  Whether  it  can  be  taken  into  the 
system  in  the  food  and  drink  is  still  an  unsettled  question. 


LECTURE    XIX. 


TYPHUS    FEVER. 
Symptoms. 

I  WILL  continue  tlie  history  of  typhus  fever  by  giving 
you  an  outline  of  the  phenomena  which  attend  its  develop- 
ment, and  afterwards  speak  of  some  of  its  more  prominent 
symptoms. 

Its  advent  is  usually  sudden — there  are  no  constant  pre- 
monitory symptoms.  In  some  cases,  for  a  few  days,  there 
may  be  a  feeling  of  indisposition,  jierhaps  of  headache,  loss 
of  appetite,  and  vertigo  ;  bur  in  a  large  majority  of  cases  it 
is  ushered  in  by  a  distinct  chill.  This  differs  from  the  chill 
of  ])neumonia  or  that  of  malarial  fever,  in  that  it  is  short, 
sharp,  and  sudden.  It  may  amount  to  nothing  more  than 
a  chilly  sensation.  Following  the  chill  there  is  a  severe 
and  steadily  increasing  headache;  it  is  frontal,  and  increases 
in  intensity  from  hour  to  hour.  This  is  accompanied  by  a 
more  or  less  severe  pain  in  the  back  and  limbs,  especiall}^ 
in  the  thighs.  The  headache  of  ty})hus  is  more  constant 
and  persistent  than  that  w  hich  attends  the  development  of 
any  other  fever;  usually,  after  a  few  days  it  diminishes  in 
intensity.  A  sen.se  of  extreme  prostration  ver}'  soon  follows 
the  ushering-in  chill.  In  some  cases  the  patient  is  com- 
pelled, within  twenty-four  hours  from  the  commencement 
of  his  sickness,  to  take  to  his  bed  from  muscular  weakness. 


218  TYPHUS   FEVER. 

This  loss  of  muscular  power  will  sometimes  sliow  itself  by 
the  unsteady,  tottering  gait  of  the  patient,  and  is  more 
marked  in  the  early  stage  of  typhus  fever  than  it  is  in  any 
other  disease.  At  one  time,  while  I  was  making  my  visit 
in  the  fever  ward,  my  house  physician,  w^ho  was  sickening 
from  typhus  fever,  staggered  and  fell  by  my  side  from  loss 
of  muscular  power.  He  died  on  the  eighth  day  of  the 
disease. 

Within  the  first  twenty-four  hours  after  the  chill  the  tem- 
perature may  rise  as  high  as  105°  F.  or  106°  F.,  although  at 
the  same  time  the  patient  may  complain  of  a  chilly  feeling, 
and  will  draw  up  to  the  fire  or  cover  himself  with  blankets. 
It  is  a  peculiarity  of  this  fever  that,  during  the  first  two 
or  three  days,  the  patient  experiences  a  sensation  of  cold- 
ness, w^iile  the  thermometer  shows  the  temperature  to  range 
at  105°  F.  or  higher.  During  the  first  week  of  the  disease 
the  temperature  remains  at  104°  F.  or  105°  F.  There  will 
be  morning  and  evening  variations,  most  marked  at  noon 
and  midnight ;  but  these  variations  follow  no  regular  course, 
as  in  typhoid  fever.  From  the  eighth  to  the  fourteenth 
day  the  temperature  is  liable  to  sudden  depression.  As  a 
rule,  the  temperature  falls  between  the  eighth  and  four- 
teenth day.  There  is,  without  doubt,  a  day  of  crisis  in  this 
disease.  In  typical  cases,  before  the  fourteenth  day  there 
is  a  marked  decline,  and  often  a  sudden  fall  in  temperalTure. 
By  the  beginning  of  the  second  week  the  temperature  ranges 
at  its  highest.  If  there  is  a  sudden  rise  in  temperature  dur- 
ing the  second  week,  it  is  almost  certain  evidence  that  some 
complication  exists. 

At  first  the  tongue  is  swollen  and  covered  with  a  white 
coating.  It  presents  very  much  such  an  appearance  as  is 
seen  in  many  nervous  affections.  As  the  disease  progresses, 
after  a  day  or  two  it  assumes  a  yellowish  brown  color,  and 
the  coating  becomes  thicker  ;  later  it  becomes  dry,  dark, 
and  fissured.  Nausea  is  sometimes  present,  rarely  vomit- 
ing. The  abdomen  is  free  from  pain,  except  over  the  liver  ; 
the  bowels  are  constipated.  Some  enlargement  of  the 
spleen  can  usually  be  detected  quite  early. 

The  pulse  is  accelerated  from  the  very  beginning  of  the 


SYMPTOMS.  219 

fever,  ranging  from  100  in  lli»'  morning  to  110  or  120  in  tho 
rvciiiim;  th."  accclcnitiou  is  grratfr  in  childrm  than  in 
adults. 

A I  the  onset  of  the  fever  tlie  ])nlse  is  full,  l)ut  it  soon 
beromt's  soft  and  eompressible,  and  Jinally  feeble.  It  is 
rarrly  dicrotic.  It  is  only  in  the  severest  cases  just  preced- 
ing dcalh  that  till'  ])alsi' becomes  irregular  and  intermitting. 
The  face  is  Hushed,  the  conjunctivjc  injected,  the  ex])res- 
sion  of  countenance  is  dull  and  heavy,  and  as  the  fever 
progresses,  the  cheeks  assume  a  mahogany  color.  The 
sleep  is  disturbed,  and  when  the  iiatient  is  awake  his  mind 
is  confused ;  in  very  severe  cases  delirium  is  very  early 
present. 

Between  the  fifth  and  eighth,  usually  on  the  fifth  day  of 
the  disease,  an  eru])ti()n  makes  its  appearance  ui)on  the  sur- 
face. It  appears  first  upon  the  sides  of  the  al)domen,  and 
gradualh'  extends  over  the  whole  anterior  ])ortion  of  the 
body,  except  the  face  and  hands.  It  is  more  marked  upon 
the  trunk  than  on  the  extremities.  At  first  the  eruption 
consists  of  dirty  pink-colored  spots,  varying  in  size  from  a 
mere  i)oint  to  three  or  four  lines  in  dianu?ter.  These  spots 
are  slightly  elevated  above  the  surface,  and  temporarily  dis- 
appear on  iirm  ])ressure. 

After  a  day  or  two  the  eruption  becomes  darker  in  color, 
and  assumes  a  purplish  hue.  It  is  no  longer  elevated  above 
the  surface,  does  not  entirely  disa])i)ear  on  firm  pressure, 
and  the  spots  have  no  well-detined  margin.  This  eruption 
is  made  up  of  irregular  spots,  varying  from  a  point  to  two 
or  three  lines  in  diameter,  either  isolated  or  grou])ed  to- 
gether in  patclies,  presenting  a  very  irregular  outline  ;  in 
children  it  often  resembles  the  eruption  of  measles.  When 
the  eruption  is  abundant  it  imparts  to  the  skin  a  mottled 
aspect,  which  has  given  rise  to  the  term  "mulberry  rash  of 
typhus."  Another  distinctive  peculiarity  is,  that  each  spot 
or  patch  remains  visible  from  its  first  a])])earanc(;  until  con- 
valescence is  established  or  death  occurs,  and  it  is  often  seen 
upon  the  bodies  of  those  who  have  died  of  typhus  fever. 

In  some  cases  of  typhus  there  are  only  a  few  s])ots  of  the 
eruption,  while  in  other  cases  they  are  very  abundant,  and 


220  TYPHUS   FEVER. 

the  surface  of  the  body  presents  the  well-marked  mottled 
appearance.  In  a  certain  proportion  of  cases,  after  the 
eruption  which  I  have  just  described  has  been  visible  for  a 
few  days,  there  will  appear,  scattered  over  the  surface, 
small  dark  spots,  due  to  minute  subcutaneous  hemorrhagic 
extravasation  ;  these  are  called  petechise.  On  this  account 
the  disease  has  been  called  petechial  typhus  ;  but  these 
petechise  are  by  no  means  distinctive  of  typhus,  for  they 
are  also  met  with  in  other  diseases.  The  majority  of  cases 
of  typhus  which  you  meet  will  have  no  eruption  except  the 
"mulberry  rash."  When  the  petechial  spots  are  ]3resent 
you  will  find  a  more  severe  form  of  the  disease,  and  more 
extensive  blood-changes  than  usual. 

In  all  severe  cases,  at  the  close  of  the  first  week  the  head- 
ache, which  has  been  the  most  troublesome  symptom,  dis- 
appears, and  delirium  comes  on.  The  delirium  will  vary 
in  character  and  severity  in  different  epidemics,  being  much 
more  violent  and  active  in  some  than  in  others.  Some- 
times, at  the  ver}^  outset  of  the  disease,  the  delirium  is  very 
active,  the  patient  shouts  and  talks  more  or  less  inco- 
herently, and  is  more  or  less  violent.  If  not  restrained,  he 
may  throw  himself  out  of  the  window.  This  period  of 
intense  nervous  excitement  may  last  two  or  three  days, 
during  which  the  countenance  becomes  livid,  the  conjuncti- 
vae injected,  the  hands  tremulous,  and  suddenly  the  patient 
may  pass  into  a  state  of  apparent  coma.  It  is  not  that 
of  complete  coma,  for  the  patient  can  be  easily  aroused  ; 
but  he  lies  upon  his  back,  with  a  tendency  to  slip  down  in 
bed,  picking  at  the  bed-clothes.  It  is  not  a  state  of  uncon- 
sciousness, although  one  of  apparent  coma,  for  tlie  mental 
processes  are  going  on  with  great  activity,  and  the  imagina- 
tion will  conjure  up  a  great  variety  of  liorrid  fancies,  and 
the  visions  which  pass  before  the  patient  will  be  distinctly 
remembered  after  recovery  has  taken  place.  This  condition 
has  been  called  "  coma  vigil."  During  this  period  the  ex- 
perience of  years  may  be  crowded  into  a  day  or  an  hour, 
and  the  patient  may  feel  that  he  has  lived  a  lifetime  while  in 
this  state.  Those  who  have  the  greatest  mental  power  and 
possess  the  highest  culture  have  the  most  distressing  fancies 


RYMI'TOMS.  221 

(lurinLT  this  soiiiiiohMit  iicriod.  U",  in  this  condition,  tlifiT  is 
a  tt'iuh'iicy  towards  a  fatal  issuf,  the  i)ati»'nt  will  jtass  into 
a  inon»  coniplt^te  stujior.  an<l  the  coma  will  Ix-conn'  more 
and  more  i)rof()nnd  ;  tlie  icsjiiration  l)ccom»'S  less  and  less 
frequent  ;  tlie  pulse,  which  has  ran,i,^ed  at  about  120  per 
minute,  rises  to  140  or  !.")(i,  and  liiially  becomes  ini]M'r(;ep- 
tible  at  the  wrist  ;  tlie  roni;-ue,  rolled  into  a  round  mass, 
becomes  brown  and  dry,  so  that  the  patient  is  unable  to 
protrude  it  from  tlie  month  ;  sordes  collect  upon  the  teeth  ; 
the  conjunctivjp  are  red,  and  the  eyes  when  open  ])resent 
a  leaden  a}>i)earance.  The  patient  has  no  longer  power  to 
move  his  body  ;  he  lies  on  his  back  with  his  head  thrown 
back.  ])t'rhaps  is  only  able  to  make  slight  tremulous  motions 
with  his  hands.  The  urine  collects  in  the  bladder,  and,  if 
not  removed  with  a  catheter,  dribbles  away.  The  extremi- 
ties become  cold,  but  the  body  temperature  remains  at  105° 
F.,  or  it  may  rise  as  high  as  107°  F.  or  108°  F.  In  one 
case  under  my  observation  it  rose  to  110°  F.  just  preceding 
death,  while  the  extremities  were  cold. 

If  the  case  is  tending  to  a  favorable  termination,  about 
the  fourteenth  day  of  the  fever  there  is  an  amelioration  of 
all  the  symptoms.  The  patient  falls  into  a  quiet  sleep,  from 
which  he  awakes  conscious  and  convalescing.  The  pulse 
and  temperature  fall,  the  tongue  becomes  clean  and  moist, 
the  delirium  subsides,  and  there  is  a  desire  for  food.  After 
two  or  three  days  the  pulse  reaches  its  normal  standard  and 
strength  gradually  returns.  This  is  an  outline  of  the  prog- 
ress of  the  disease  in  a  severe  case  of  typhus  fever,  termi- 
nating either  in  death  or  in  recovery.  In  a  mild  case  there 
will  lie  no  delirium.  The  temperature  may  nr)t  rise  above 
102°  F. ;  the  tongue  is  neither  brown  nor  dr3^  There  is  no 
great  acceleration  of  the  ]uilse,  never  beating  faster  than  120 
per  minute,  and  that  only  for  a  very  short  j)eri()d. 

During  the  entire  course  of  a  severe  or  mild  case  of  ty- 
phus f»*ver,  there  is  no  gastric  or  intestinal  disturbance,  no 
diarrlnra,  no  distention  of  the  abdomen,  no  ])ain  in  tin- right 
iliac  f<jssa',  no  gurgling^-in  a  word,  no  al)dominal  symji- 
toms. 

In  mild  cases  the  eruption  is  never  very  abundant,  l)ut  it 


TYPHUS   FEVER. 

apjiears  on  the  fifth  day,  and  remains  visible  nntil  conva- 
lescence is  established. 

I  will  now  speak  in  detail  of  the  more  important  symp- 
toms ;  those,  in  fact,  which  determine  the  character  of  the 
fever. 

I  have  already  stated  that  symptoms  indicating  disturb- 
ance of  the  nervous  system  are  among  the  earliest  and  most 
prominent. 

Of  these,  JieadacTie  is  one  of  the  most  constant.  For  the 
first  week  or  ten  days  it  is  severe  and  persistent,  after  which 
time  it  gradually  abates,  and  disappears  towards  the  close 
of  the  second  week. 

Delirium  comes  on  usually  about  the  eighth  day  ;  some- 
times it  is  present  at  the  onset  of  the  disease.  At  whatever 
period  it  may  be  developed,  it  will  continue  until  the  termi- 
nation of  the  disease.  At  first  the  delirium  shows  itself  at 
intervals  during  the  night,  or  lasts  all  night,  to  disappear 
during  the  day.  Its  character  varies  from  a  low,  muttering 
form,  to  a  very  active  and  noisy  delirium. 

Every  possible  variation,  as  it  were,  is  met  with  during 
an  epidemic  of  typhus  fever.  Acute  delirium  is  more  liable 
to  be  present  with  the  intelligent  and  highly  cultured,  while 
the  delirium  is  usually  low  and  muttering  in  character  in 
the  case  of  the  aged  or  uncultured. 

Stvpor  or  somnolence  in  some  degree  is  seldom  absent. 
It  may  develop  with  or  without  previous  delirium.  Usu- 
ally, as  the  case  progresses  towards  a  fatal  termination, 
stupor  comes  on  ;  this  becomes  more  and  more  profound  as 
the  disease  advances.  The  patient  often  lies  for  hours  ap- 
parently unconscious,  with  his  eyes  open  as  though  awake, 
but  he  is  absolutely  indifi'erent  to  all  that  is  going  on  around 
him.  This  is  a  condition  to  which  the  term  "coma  vigil" 
has  been  applied.  It  is  almost  invariabl}^  followed  by  a 
fatal  termination.  Sometimes  coma  comes  on  suddenly, 
without  any  antecedent  somnolence  ;  under  such  circum- 
stances the  urine  will  be  found  loaded  with  albumen. 

The  brain  symptoms  appear  much  earlier  in  typhus  than 
in  t3^plioid  fever.  Loss  of  mnscidar  strength  is  an  early 
and  striking  symptom  in  typhus  fever.     In  the  majority  of 


SYMPTOMS.  223 

cast'!?,  it  is  ]iivsent  from  (ht*  vciy  first  da}'  of  the  ffvcr.  In 
many  cases,  as  tlu'  fcvrr  ])r()!i-r<'ss«'s,  tlu'  loss  of  muscnlar 
power  is  so  f]jreat  that  the  ])ati<'nt  is  nii;il)Ii-  to  liini  in  Ix-d  ; 
the  prostration  alwtiys  increases  as  the  disi-asf  adNanccs. 
Ill  some  cases  there  is  little  loss  of  stren<:;tli  durinir  the  iirst 
week,  but  tlie  prostration  comes  on  suddenly  durinir  the 
second  week  of  the  disease.  Tn  addition  to  the  general  loss 
of  muscular  power,  in  certain  cases  there  is  paralysis  of 
some  muscles,  such  as  the  sphincter  an!  and  tlie  muscles  of 
the  bladder,  so  that  the  urine  and  f;pces  are  dischar,<j;ed  in- 
voluntarily. If  the  muscular  coat  of  the  bladder  becomes 
paralyzed,  there  is  retention  of  urine. 

Pysphairia,  partial  or  complete  aphonia,  and  inability  to 
protrude  the  tongue,  are  due  to  paralysis  of  the  muscles. 

Muscular  tremor  is  an  indication  of  very  great  muscular 
prostration,  and  is  usuall}^  met  with  in  the  aged  and  intirm, 
and  in  those  who  have  been  addicted  to  the  use  of  intoxi- 
cating drinks. 

Muscular  spasms  and  subsultus  tendinum  are  present  to 
a  greater  or  less  degree  in  all  severe  cases  ;  the  tendons  of 
the  wrist  are  most  frequently  affected.  One  form  of  these 
spasmodic  movements  is  manifested  by  the  patient's  picking 
or  fumbling  the  bed-clothes  ;  another  by  obstinate  hiccough. 
All  these  symptoms  must  be  regarded  as  of  very  grave 
import. 

General  convulsions  are  of  rare  occurrence ;  but  if  thoy 
do  occur,  they  must  be  regarded  as  an  alarming  sym]itom, 
as  they  are  usually  caused  by  uraemia.  They  are  most 
liable  to  occur  towards  the  close  of  the  second  week  of  the 
fever. 

Emaciation  is  never  as  marked  a  sj'mptom  of  typhus  as 
of  tvphoid.  It  is  rarely  present  to  aiu'  great  degree  before 
the  third  week  of  the  fever. 

Temperature. — During  the  first  week  of  typhus  fever 
there  are  no  such  marked  ty])ical  variations  in  temjierature 
as  are  m«'t  with  in  typhoid — non«»  that  will  enable  you  to 
make  a  diagnosis.  Usually  the  temperature  rises  rapidly 
from  the  very  onset  of  the  fever,  and  in  cases  of  average 
severity  attains  its  maximum  on  or  before  the  second  or 


224  TYPHUS   FEVER. 

third  day  of  the  disease.     At  this  period  the  evening  tem- 
perature will  range  between  103^  F.  and  106°  F. 

Before  the  temperature  reaches  its  maxim uni,  tlie  morn- 
ing and  evening  variations  are  slight.  After  the  tem- 
perature has  reached  its  maximum,  for  several  days  there 
will  be  little  change  ;  but  at  some  time,  usually  between 
the  seventh  and  tenth  day,  there  will  be  a  slight  remission 
until  the  twelfth  or  fourteenth  day,  when  it  rapidly  falls, 
in  typical  cases  that  terminate  in  recovery,  to  its  normal 
standard. 

Occasionally  an  elevation  of  two  or  more  degrees  pre- 
cedes the  fall.  This  sudden  fall  about  the  fourteenth  day 
is  peculiar  to  typhus.  A  very  high  range  of  temperature 
during  the  first  week  is  an  indication  that  severe  cerebral 
symptoms  will  be  developed  during  the  second  week  of  the 
fever.  If  a  very  sudden  rise  in  temperature  occurs  during 
the  second  week,  it  indicates  the  occurrence  of  some  com- 
plication. 

A  case  of  typhus  fever  may  terminate  fatally,  in  which 
the  temperature  at  no  time  has  exceeded  103°  F.  In  all 
fatal  cases,  just  preceding  death  there  is  usually  a  rise  of 
two  or  three  degrees  in  temperature.  During  the  first  week 
of  convalescence  the  temperature  often  remains  below  the 
normal  standard,  especially  in  the  morning. 

Pulse. — The  pulse  in  this  fever  is  usually  frequent,  soft, 
easily  compressed,  and  often  irregular.  The  heart  may  par- 
take of  the  general  muscular  weakness,  so  that  the  first 
sound  may  become  inaudible. 

In  the  severe  cases,  during  the  first  week  the  pulse  may 
reach  120  beats  per  minute,  after  wliicli  time  it  increases  in 
frequency  and  feebleness  with  the  severit}^  of  the  general 
symptoms.  By  the  third  day  it  may  reach  120  beats  per 
minute,  usually  in  the  milder  case  it  does  not  exceed  on 
that  day  100  beats  per  minute.  If  during  the  first  week  it 
continues  for  three  consecutive  days  so  frequent  as  120  beats 
per  miiiute,  it  is  an  almost  certain  indication  of  danger. 
The  higher  the  temperature,  and  the  more  frequent  the 
pulse  during  the  first  week,  the  more  severe  will  be  the 
symptoms  during  the  second  week.     If  during  the  second 


sYMrTC):\r:=^.  225 

week  it  becomes  small,  ft'chlf,  and  fn-cpicnt,  jxTliaps  bcatinj^ 
140  or  ir)0  per  minute,  you  may  re<xar<l  iIh'  case  as  a  V(,'ry 
unfavorable  oin', 

111  this  (lisi-asc,  a  favoi-abl*'  (•lian,iz;e  is  ol'ti-n  marked — first, 
by  a  gradual,  and  tinally  by  a  sudden  diminisiiing  in  the 
frequency  of  tlif  jjuIsi'.  Wh-'ii  this  is  followed  by  a  sud- 
d»Mi  increase  in  frcipifucy,  you  may  look  for  some  compli- 
cation. 

During  the  tirst  wcrk,  if  tlic  ])uls('  increases  in  frequency 
the  temperature  rises,  and  if  the  ])uls<'  diminishes  in  fre- 
quency the  temperature  falls ;  but,  during  the  second 
week,  the  pulse  may  increase  in  frequenc3%  and  yet  the  tem- 
perature may  fall,  and  the  pulse  may  diminish  in  frequency 
and  yet  the  temperature  rise. 

The  pulse  is  not  an  infallible  guide  as  to  the  condition  of 
the  heart,  for  sometimes  the  pulse  is  full  and  distinct  while 
the  heart  power  is  very  much  enfeebled  :  on  the  other  hand, 
the  cardiac  im})ulse  may  appear  strong  and  the  sounds  dis- 
tinct, and  yet  the  radial  pulse  may  be  imperceptible.  In 
most  fatal  cases,  after  the  first  week  the  radial  pulse  is  im- 
perceptible for  several  days  prior  to  death.  Although  in 
most  severe  cases  of  typhus  fever  there  is  a  rapid  pulse, 
yet  a  slow  pulse  does  not  necessarily  indicate  a  mild  attack. 

Erupiion. — The  general  character  of  the  erui)tion  of 
typhus  fever  has  already  been  described. 

I  will  repeat  some  statements  already  made  to  you.  The 
eruption  a])pears  on  the  sixth  or  seventh  day  of  the  fever. 
Its  appearance  is  preceded  and  accompanied  by  a  fresh  red- 
ness of  the  whole  surface,  on  which  daik  red  spots  are 
scattered,  giving  the  skin  a  mottled  aj)pearance.  These 
spots  have  an  irregular  outline,  and  vaiy  in  size  from  a 
■j)oint  to  three  or  four  lines  in  diamet«'r.  Sometimes  they 
are  few  in  number,  but  more  commonly  they  are  numerous ; 
the  larger  spots  are  formed  by  the  coalescence  of  the  smaller 
ones.  At  first  they  have  a  dusky  ])ink  hue,  ])aitialh'  or 
wholly  disappearing  on  pressure,  and  as  the  linger  i)as.ses 
over  them  they  seem  to  be  slightly  elevated.  After  a  day 
or  two  they  assume  .sommvhat  of  a  brick-dust  color,  and  are 
but  slightly  changed  by  }>ressure  ;  then  the  color  of  the 
15 


226  TYPHUS   FEVER. 

spots  becomes  still  darker  and  darker  in  hue,  and  finally 
they  are  not  affected  by  firm  pressure.  Another  peculiarity 
is  that  each  patch  or  cluster  remains  visible  from  its  first 
appearance  until  the  termination  of  the  disease.  The  erup- 
tion may  appear  upon  any  portion  of  the  body.  Usually 
it  first  makes  its  appearance  upon  the  tj-unk,  soon  spread- 
ing to  the  extremities ;  ver}^  rarely  is  it  seen  on  the  face. 
When  the  eruption  is  scanty,  it  is  limited  to  the  chest  and 
abdomen.  In  some  patients  the  eruption,  though  well  de- 
veloped, is  not  prominently  marked  ;  the  spots  are  pale 
and  undefined,  and  though  grouped  in  patches  are  so 
irregular  that  they  give  to  the  entire  surface  a  faint,  dingy 
appearance.  The  question  now  arises,  is  the  presence  of 
this  eruption  so  constant  in  typhus  fever  that  by  it  we  may 
with  certainty  make  the  diagnosis  of  this  disease  1 

I  believe  that  it  may  be  discovered  by  a  careful  examina- 
tion in  nearly  every  case  of  typhus  fever  ;  it  is  more  likely 
to  be  indistinct  in  children  than  in  adults. 

When  typhus  fever  is  prevailing,  an  ephemeral  fever  is 
often  met  with,  which  has  many  of  the  prominent  s^anptoms, 
but  not  the  characteristic  eruption  of  typhus  fever.  This 
ephemeral  fever  or  febricula  is  undoubtedly  due  to  typhus 
poisoning,  yet  it  is  not  typhus  fever.  In  a  case  of  fever, 
where  there  is  a  question  as  regards  diagnosis  between  ty- 
phus, typhoid,  malarial,  and  septic  fever,  all  of  which  have 
many  phenomena  in  common,  I  should  not  be  willing  to 
make  the  diagnosis  of  typhus  fever  unless  the  eruption  was 
present. 

RespvTatioii. — Usually,  during  the  first  week,  the  res- 
j)irations  do  not  exceed  twenty  or  thirty  per  minute,  but 
during  the  second  week  they  often  run  up  to  forty  or  fifty 
per  minute.  In  cases  where  there  is  great  prostration  ac- 
companied by  stupor,  the  respirations  sometimes  fall  to 
eight  or  ten  per  minute.  Under  such  circumstances  they 
are  often  irregular  and  puffing  in  character.  Hypostatic 
congestion  of  the  lungs,  if  extensive,  is  attended  by  great 
frequency  of  respiration  and  evidences  of  cyanosis.  The 
occurrence  of  these  changes  in  respiration  ought  always  to 
lead  you  to  make  a  careful  examination  of  the  chest.     The 


SYMPTOM:^.  227 

breath  of  a  ty]>hus  fever  patient  lias  an  odor  wliicli  closely 
resembles  that  exhaled  bv  the  skin. 

Thi'  (I  iff  est  ire  sf/stc/ii.  which  is  so  icieatiy  all'ected  in  ty- 
]>h(»id  fever,  is  v.-ry  lilth',  if  at  all,  disturlx'd  in  tyjihiis 
fever.  Nansea  and  voinitiiiir  are  rare,  and  an  examination 
of  till'  alxlomen  presi'nls  nothing  abnormal.  There  is  no 
tym))anitis  or  tenderness  ou  pressure.  Spontaneous  diar- 
rlid'a  is  of  exceedingl}'  rare  occurrence;  the  bowels  are 
generally  consti]tated.  Intestinal  InMnorrhage  is  of  rare 
occurrence,  and  when  it  is  present  depends  either  upon 
congestion  of  the  mucous  mend)rane  of  the  colon  or  on 
hemorrhoids,  which  accompany  an  engorged  portal  circu- 
lation. 

Urine. — The  urine  in  typhus  undergoes  important 
changes.  The  quantity  varies  somewhat  with  the  amount 
of  fluid  taken  into  the  stomach  ;  usually  it  is  diminished 
during  the  iirst  week,  sometimes  to  one-fourth  the  normal 
quantity.  In  the  advanced  stage  of  severe  cases  there  is 
sometimes  complete  suppression  of  urine,  but  more  fre- 
quently the  quantity  of  urine  increases  during  the  later 
stages  of  the  fever. 

The  quantity  of  urea  excreted  in  twenty-four  hours  dur- 
ing the  first  few  days  of  the  fever  is  increased,  and  the  in- 
crease is  in  ])roportion  to  the  intensity  of  the  fever.  In  the 
majority  of  cases  it  remains  abnornuilly  increased  until  the 
period  of  crisis  is  reached  (about  the  fourteenth  day),  when 
it  gradually,  or  in  some  instances  ra])idly,  falls  below  the 
normal  standard. 

In  all  severe  cases,  during  the  first  week  of  the  disease, 
a  small  amount  of  albumen  is  always  found  in  the  urine ; 
when  the  quantity  is  large,  the  case  may  be  regarded  as  very 
severe. 

In  the  severer  cases  the  urine  will  also  be  found  to  con- 
tain vesical  and  renal  ejnthelium,  and  when  the  (piantity  of 
albumen  is  large,  epithelial  and  fatty  casts  of  the  urinifer- 
ous  tubes  will  l)e  ]>resent. 

In  this  connection  it  is  important  to  bear  in  mind  the  ne- 
cessity of  daily  inquiry'  into  the  expulsive  power  of  the 
bladder.      When   there   is  little  cerebral  disturbance,   the 


228  TYPHUS   FEVER. 

urine  is  passed  witliout  difficulty  ;  bnt  wlieii  stupor  and 
a  tendency  to  coma  exist,  there  is  often  retention  or  an 
involuntary  dribbling  of  urine,  wliicli  might  lead  one  to 
think  that  there  was  no  accumulation  of  urine  in  the 
bladder. 

It  is  safe  to  inquire,  at  least  once  a  day,  as  to  the  state  of 
this  organ,  and  if  involuntary  discharges  of  urine  occur, 
the  contents  of  the  bladder  should  be  evacuated  by  means 
of  a  catheter. 


LECTURE     XX. 


TYPHUS  FEVER. 

Sympfovis.— Differential  Diagnosis^. —Pror/nosis. 

This  inoniiiii;-  I  Avill  si)eak  of  the  complications  of  typhus 
fever,  and  its  differential  diagnosis. 

In  typhus  as  well  as  in  typhoid  fever,  you  must  be  pre- 
pared for  the  occurrence  of  com  plications.  Altliough  they 
do  not  properly  belong  to  tlic  primary  disease,  yet  they 
so  modify  it  that  they  enter  very  largely  into  its  history. 
Reference  has  already  been  made  to  them  under  tlie  lunid 
of  anatomical  lesions,  yet  it  is  necessary  that  I  should 
again  speak  of  them  under  the  head  of  symptoms.  In 
a  large  number  of  cases  which  terminate  fatally,  drath  is 
due  to  some  one  of  these  complications.  Most  of  these 
commence  before  the  cessation  of  the  primary  fever;  oc- 
casionally convalescence  is  interrupted  by  their  occur- 
rence, and  indefinitely  prolonged.  Doubtless,  in  in;iiiy  in- 
stances, tln'y  de])end  upon  the  weaken. 'd  condition  of  the 
lieart  induced  by  the  ty])lius  poison.  In  some  r])idemics 
they  are  all  pulmonary;  in  others  they  are  all  c.'r.'bral. 
The  advent  of  i)ulmonary  complications  in  this  fever  is  al- 
ways insidious  ;  tin;  cough  and  expectoration  which  usually 
attend  pulmonary  diseases  are  either  absent,  or  so  slight  as 
not  to  attract  the  attention  of  the  physician. 

Frequently,  rapid  l)r<'atiiing  and  lividity  of  the  face  are 
the  first  obvious  indications  of  extensive  disease  of  the 
lungs.  When  these  symi)toms  are  prescMit,  a  careful  ]»hysi- 
cal  examination  of  the  chest  should  be  madf. 


230  TYPHUS   FEYEK. 

Broncliith  may  come  on  at  any  period  during  tlie  fever, 
and  it  may  continue  after  the  fever  has  subsided.  So  long 
as  it  is  confined  to  the  larger  tubes  there  is  little  danger, 
but  sometimes  suddenly  and  insidiously  it  extends  into  the 
smaller  tubes  and  is  complicated  with  pulmonar}^  congestion 
and  oedema.  Under  such  circumstances  it  may  be  the  direct 
cause  of  death. 

The  pneumonia  which  comi)licates  typhus  fever  is  lobular 
in  character,  and  frequently  is  preceded  or  accompanied  by 
bronchitis.  It  has  a  tendency  to  terminate  in  abscess  or 
gangrene.  During  life  it  is  not  always  possible  to  distin- 
guish it  from  hypostatic  congestion.  If,  however,  the  dul- 
ness  on  percussion  is  confined  to  one  lung,  if  the  respiration 
is  bronchial  and  the  pneumonic  sputa  is  present,  the  pneu- 
monia is  readily  established.  The  seat  of  the  pneumonia  is 
generally  at  the  upper  portion  of  the  lung. 

Laryngitis  is  sometimes  a  very  serious  complication  of 
typhus.  It  may  be  croupous  in  character,  but  the  more 
common  form  is  that  of  acute  oedema  glottidis.  Its  occur- 
rence is  readily  recognized  by  the  signs  of  laryngeal  obstruc- 
tion which  attend  its  development.  Whenever  3-ou  meet 
with  extensive  swelling  of  the  glands  about  the  neck,  with 
great  tumefaction  of  the  mucous  membrane  of  the  pharynx, 
you  must  be  on  the  watch  for  the  occurrence  of  this  compli- 
cation. 

On  account  of  the  extensive  blood-changes  which  some- 
times occur  in  severe  cases  of  typhus  fever,  the  blood  readily 
escapes  through  the  walls  of  the  vessels,  giving  rise  to  ex- 
tensive hemorrhages  from  the  mucous  surfaces  and  into  the 
cellular  tissue.  The  occurrence  of  the  hemorrhages  is  pecu- 
liar to  certain  epidemics,  and  when  they  occur  it  is  during 
the  first  week  of  the  fever. 

Meningitis  is  the  only  cerebral  complication  which  you 
will  probably  meet  with  in  this  fever.  This  occurs  more 
frequently  in  children  than  in  adults,  and  is  not  present  in 
every  epidemic.  The  cerebral  symptoms,  which  are  such 
constant  attendants  upon  typhus  fever  (as  I  have  already 
stated),  do  not  depend  upon  meningeal  inflammation  ;  thpy 
belong  to  the  regular  history  of  the  disease.     If,  during  the 


SYMrTOM>?.  231 

coiirso  of  tho  fever,  tlinv  is  a  (Icrp-seatcd  ]):iiM  in  tin*  licad, 
with  ivstU'Ssncss,  wliich  siiows  itself  by  a  coii-laiil  atttMiii)t, 
to  <?('t  out  of  bed,  witli  pii()t()i)lu)l)ia,  contract. d  ].npil-.  and 
tlusliiuiz:  of  the  face  and  eyes,  followed  by  soiuiioleiice  grad- 
ually lai)sing  into  coma,  you  may  be  almost  certain  that 
meningitis  is  occuning  as  a  complication.  This  is  most  lia- 
ble to  occur  durinii;  the  second  wtM'k  of  the  fever.  The  char- 
acteristic sym])toin  which  marks  its  development  is  the  con- 
stant attem])t  oil  tlie  parr  of  tlie  patient  to  get  out  of  l)i'd. 
He  is  so  ])ersistent  in  this  that  uidess  watched  with  the 
greatest  care  he  will  be  found  upon  the  floor,  vainly  at- 
tempting to  rise.  The  patient  has  more  muscular  power 
than  before  the  occurrence  of  the  meningf-al  comi)lication, 
for  lie  will  p<M-form  acts  which  previously  he  was  wholly 
unable  to  perform.  Usually  the  delirium  lasts  two  days, 
then  the  patient  gradually  passes  into  a  state  of  coma  from 
which  he  cannot  be  aroused  ;  his  respirations  may  not  be 
more  than  eight  or  ten  per  minute.  Dilatation  of  the  pupils, 
and  an  intermitting  and  almost  imperceptible  pulse,  imme- 
diately precede  death. 

I  have  already  referred  to  the  anatomical  changes  in  the 
kidney's,  which  are  so  frequently  met  with  in  the  course  of 
this  fever.  I  pn^fer  to  regard  most  of  these  changes  as  a 
part  of  the  history  of  the  fever  rather  than  as  a  complica- 
tion, although  in  some  few  instances  croupous  nephritis  oc- 
curs, which  must  be  included  in  the  list  of  complications. 
Its  occurrence  in  the  cours»?  of  tyi)hus  fever  is  indicated  by 
the  almost  entii-e  su])pression  of  urine,  and  by  tin'  ])resence 
of  albumen  in  the  urine,  and  exudative  and  blood  casts. 

cnuinhihtr  fiirrniiu/s  are  also  occasional  complications 
of  tv])hus  fever,  and  sometimi's  may  lie  of  a  very  serious 
natuie,  for  they  may  so  interfere  with  deglutition  and 
res])iration  as  to  destroy  the  life  of  the  ])atient.  These 
swellings  usually  appear  immediately  aftt-r  the  crisis  of  the 
primary  fever.  They  often  enlarge  with  great  ra])idity,  and 
in  some  instances  terminate  in  ext<'nsive  supi)uration. 

I  have  now  briefly  given  you  an  <»utline  of  the  s^nnjitoms 
which  mark  the  development  and  ])rogress  of  a  case  of  ty- 
phus f.'V.M\  and  also  of  the  promin'-nr  complications  which 


232  TYPHUS   FEVER. 

may  occur  during  its  progress.  There  are  certain  accidental 
or  occasional  complications  which  cannot  strictly  be  re- 
garded as  a  part  of  the  history  of  this  fever,  as  they  may 
occur  with  any  other  fever.     To  these  I  shall  not  refer. 

Duration. — The  duration  of  typhus  fever  is  considera- 
bly shorter  than  that  of  typhoid  fever,  and  it  is  of  great 
importance,  both  as  regards  prognosis  and  treatment,  to  be 
able  to  fix  the  time  of  its  continuance.  Usually  the  day  of 
crisis  is  between  the  tenth  and  sixteenth  day.  The  average 
duration  of  the  fever  is  thirteen  or  fourteen  days.  It  is  of 
shorter  duration  with  the  young  than  with  the  old,  with 
children  than  with  adults. 

Relapses  are  extremely  rare  in  this  fever.  I  have  met 
with  a  second  and  third  attack  of  the  fever  in  the  same 
individual,  but  I  have  never  met  with  a  true  relapse. 

Typhus  fever  varies  very  slightly  in  its  general  character 
in  different  cases.  Authors  have  described  a  number  of 
different  varieties,  depending  on  the  mildness  or  severity  of 
the  disease,  the  prominence  of  certain  symptoms,  the  pres- 
ence of  complications  and  the  circumstances  under  which 
the  fever  appears  ;  but  the  general  description  of  the  fever 
which  I  have  already  given  you  includes  that  of  the  so- 
called  different  varieties. 

Differential  Diagnosis. — Before  the  appearance  of  the 
eruption,  the  diagnosis  of  typhus  fever  is  always  difficult, 
and  sometimes  impossible.  The  diseases  with  which  it  is 
most  liable  to  be  confounded  are  typlioidfemr,  relapsing 
fever,  measles,  pneumonia,  acute  Briglifs  disease,  menin- 
gitis, delirium  tremens,  and  some  of  the  other  acute  blood 
diseases,  such  as  erysipelas,  pycemia,  septiccemia,  etc. 

The  early  characteristic  symptoms  of  typhus  fever  are 
chilliness,  pain  in  the  back  and  limbs,  and  headache. 
During  the  first  week  the  headache  increases  in  severity  from 
hour  to  hour,  and  is  accompanied  by  a  rapid  rise  in  tem- 
perature. These  symptoms  occurring  in  one  who  has  been 
exposed  to  typhus  poison  are  almost  sufficient  for  a  diag- 
nosis.   The  appearance  of  the  eruption  settles  the  question. 

On  account  of  the  similarity  in  appearance  of  the  eruption 
of  typhus  fever  and  that  of  measles,  in  children,  the  one 


Difi'Kitr.XTiAL  T)T.\r;\Msis.  233 

disease  is  soini'limcs  iiiistakiii  lor  ihc  otlicr.  Tii  botli  dis- 
eases tlie  enii)ti()ii  may  apjx'Mr  cii  i  In-  lift  li  <l;iy,  hut  the  mi])- 
tion  of  measles  is  of  a  bri.i^lih'r  tiiil  lli:iii  that  of  typlius 
fever,  and  its  appraraiice  is  picccdi'd  by  a  ('(tui;-!!  and  ro- 
ryza,  which  ai-r  ii<>r  ])r('srnr  in  tyi)hiis  fever. 

Mcniiu/ifis.  'I'hf  (lilVcivntial  tlian'nosis  betweni  tyjiliiis 
fever  and  (•tM-t'bro-s})iiial  ini'iiiii,i;itis  is  difHciilt.  Not  iiii- 
frequeutly,  days  may  elai)se  bcfon;  you  are  abh;  to  decide 
whether  a  case  is  one  of  typlius  fever  or  of  cerebro-spinal 
meningitis.  To  show  liow  ditricult  is  the  dia,2;nosis  between 
these  two  affections,  I  will  mention  a  circumstance  which 
occurred  a  short  time  since  in  l^M'llevue  Hospital.  A  pa- 
tient was  brought  into  the  hos])ital  directly  from  a  slop, 
and  the  diagnosis  of  cerebro-s])inal  meningitis  was  made  by 
several  of  the  att^mding  staff  ;  but  at  the  autopsy  there  were 
found  none  of  the  lesions  of  meningitis,  but  all  the  changes 
corresponded  to  those  found  at  the  autopsies  of  patients 
dying  of  typlius  fever. 

Yet  there  are  many  distinguishing  points  of  difference 
between  the  two  diseases.  The  headache  of  meningitis,  at 
the  outset  of  the  disease,  is  more  distressing  than  that  of  ty- 
phus, and  it  alternates  with  delirium.  These  are  the  early 
sym])toins  of  meningitis.  When  delirium  com(>s  on  in  ty- 
l)hus  fever,  the  pain  in  the  liead  ceases. 

Pliotophobia  and  contracted  pupils  are  among  the  early 
symptoms  of  meningitis,  and  the  patient  is  greatly  dis- 
turlx'd  by  noise,  while  in  typhus  fever  he  seems  indifferent 
to  both.  Inequality  oC  the  pupils,  strabismus,  ptosis,  and 
])aralvsis  are  common  in  meningitis  and  ran?  in  typhus. 
In  meningitis  the  countenance  is  expressive  of  ])ain,  wild- 
ness,  and  anxiety  ;  in  tyi)lius  f.-vi-i-  ir  is  l)lank  and  stupid. 

Again,  in  m^'uingitis  the  ])ulse  is  lirst  slow  and  full,  then 
rai)id  and  irregular,  and  lastly  intermitting  ;  while  in 
typhus  fever  it  is  lapid  at  the  outset  of  the  disease,  and  is 
easil}'  compressed. 

Lastly,  the  eruittiou  of  typhus  fcviT  js  diaractfristic.  If 
an  eruption  is  present  in  nu'iiingitis,  it  has  no  regularity 
in  its  development  ;  it  may  a])))ear  within  twenty-four 
hours  after  the  development  of  the  lirst  symi)tom  of  the 


234  TYPHUS   FEVER. 

disease,  or  it  may  be  postponed  for  several  days,  or  it  may 
not  appear  at  all.  It  does  not  appear  on  the  fifth  or  sixth 
day  of  the  disease,  with  the  nniform  regularity  of  the  erup- 
tion of  typhus  fever.  You  may  find  petechia?  in  meningitis 
as  well  as  in  typhus  fever,  but,  as  I  have  already  told  you, 
tluy  are  not  characteristic  of  the  latter  disease. 

The  temperature  rises  more  rapidly  in  typhus  fever  than 
in  meningitis,  and  reaches  a  higher  range.  Rigidity  of  the 
muscles  of  the  neck  is  not  always  positive  evidence  of 
meningitis,  for  sometimes  it  occurs  in  typhus  fever. 

Pneumonia. — Sometimes  a  latent  pneumonia  with  ty- 
phoid symptoms  is  mistaken  for  typhus  fever  ;  especially  is 
this  the  case  when  the  latter  is  prevailing.  I  frequently 
saw  cases  where  such  a  mistake  had  been  made,  while  in 
charge  of  the  typhus  fever  patients  on  Blackwell's  Island, 
during  the  epidemic  to  which  reference  has  been  made. 
In  these  cases  you  will  have  active  typhoid  symptoms, 
such  as  dry  tongue,  delirium,  high  temperature,  etc.  The 
countenance  in  this  pneumonia,  although  the  cheeks  may 
have  a  purplish  hue,  does  not  exhibit  that  dull,  heavy 
expression  so  commonly  seen  in  typhus  fever.  Although 
there  may  be  delirium  in  both  instances,  the  delirium  in  the 
former  disease  is  of  a  milder  type  than  in  the  latter.  The 
characteristic  pneumonic  expectoration  is  not  usually  pres- 
ent in  these  cases,  and  you  must  not  therefore  rely  upon 
that  symptom  in  making  your  differential  diagnosis.  The 
physical  signs  of  pulmonic  consolidation  will  lead  you  to 
pneumonia,  and,  unless  the  typhus  eruption  is  present, 
this  will  be  sufficient  for  a  diagnosis.  If  pulmonary  con- 
solidation is  a  complication  of  typhus  fever,  it  will  not  be 
developed  until  after  the  sixth  day  of  the  fever,  the  time 
when  the  eruption  should  have  appeared.  If  no  eruption 
is  present,  the  pneumonic  consolidation  may  be  regarded  as 
the  primary  affection,  and  the  symptoms  which  simulated 
those  of  typhus  fever  may  be  regarded  as  secondary. 

Delirium  Tremens.— T[\^i  delirium  of  "delirium  tremens" 
may  sometimes  so  closely  resemble  that  of  typhus  fever, 
that  the  one  may  be  mistaken  for  the  other.  The  mistake 
has  been  made  in  Bellevue  Hospital,  and  typhus  fever  pa- 


DIFFKKKNTIAI,    I>I  ACXO.SIfl,  23.") 

tients  liavr  Ix-.-n  phic'd  in  tin- cells,  sii])])()sin^  tln'in  to  bo 
casi's  of  (Iclirinin  hvmcii^.  If  iIm'  *-(ltTirimii  ri-cinrns"  is 
iiiu'oin])licaft'(l  hy  |mfimi(ini:i,  l:ik<-tlic  tciiipi'iat  iiic  of  tho 
patieiii  ;  tlhii  ii  will  Itc  very  easy  to  make  :i  (lilTcrential 
(.liairiiosis.  for  in  "(Idirium  trciiKMis"  the  fcmjMMatiire  is 
rarely  above  lOO"  F.,  while  in  lypliiis  fever  willi  (leljriiim 
tlie  tlieniioiiietrieal  ian,<;e  is  104°  F.  or  105"  F.  You  may 
have  a  rai)i(l  jmlse  in  (h'lirium  tremens,  and  often  the  patient 
lias  a  brown,  dry  tonuiie.  and  other  typhoid  synqitoms ; 
but  there  is  only  a  sliu'lir  rise  in  temiterat  ure ;  besides, 
tlu're  is  no  eru])tion  ])resent.  The  attaclv  is  not  nsliered  in 
by  lieadache,  but  by  an  inability  to  slet'}),  and  the  circum- 
stances which  })recede  and  give  rise  to  such  an  attack  will 
establish  beyond  a  dou1)t  the  true  nature  of  the  attack. 

Acuti'  Bri(/hf'!<  I>isr((se. — It  is  not  surprising  that  acute 
urjcmia  from  acute  parenchymatous  nephritis  should  be 
mistaken  for  tyi)hus  fever.  The  brown,  dry  tongue,  the 
tendency  to  stupor,  the  contracted  pupil,  the  low  mutter- 
ing delirium,  and  all  the  phenomena  of  the  typhoid  state, 
as  well  as  the  albuminous  urine,  belong  to  both  diseases  ; 
but  the  temperature  is  not  raised  in  unemia  as  it  is  in  typhus 
fever,  and  the  cpdema  which  is  always  present  in  acute 
uraemia  is  absent  in  typhus  fever. 

Erysipelas,  pyaMuia,  septictpmia,  and  all  similar  acute 
blood  diseases  are  often  attended  by  many  of  the  symptoms 
which  attend  tin?  development  of  ty})hus  fever. 

In  pyaMuia  and  sei)tica'mia  you  have  irregular  chills, 
followed  by  fever  and  })rofuse  sweats,  with  evidences  of 
septic  and  ]iya'inic  ])oisoning  ;  in  erysipelas,  you  have  the 
evidences  of  a  localized  i)hlegmon.  You  must  remember 
that  erysipelas  is  sometimes  ushered  in  by  all  the  phenomena 
that  attend  the  ushering  in  of  typhus  fever;  this  is  before 
the  local  inflammation  shows  itself.  In  such  cases  it  is  im- 
possible to  make  a  difl*erential  diagnosis  until  the  local 
phenomena  which  chaiacterize  erysipelas  show  themselves, 
or  until  the  typhus  eiuption  apiiears.  In  many  of  the  acute 
infectious  diseases  you  will  be  comi»elled  to  wait  until  the 
time  for  the  a])p-'aiance  of  the  erui>ti(»n  before  you  can  ex- 
clude tyi»hiis  fever. 


236  TYPHUS   FEVEE. 

When  typlins  fever  is  prevailing,  and  yon  are  M^atchful 
in  regard  to  its  appearance,  you  will  usually  have  little 
difficult}^  in  diagnosis. 

You  must  alway  bear  in  mind  that  sometimes  typhoid, 
typhus,  and  relapsing  fever  prevail  at  the  same  time,  in  the 
same  locality. 

The  importance  of  early  forming  a  correct  differential 
diagnosis  between  typhus  and  typhoid  fever  cannot  be  over- 
estimated; and  in  order  that  you  may  be  the  better  able  to 
accomplish  this,  I  will  now  review  the  prominent  symptoms 
of  each,  and  compare  them.  By  so  doing,  we  shall  review 
their  etiology,  morbid  anatomy,  etc. 

The  first  point  to  be  considered  in  the  differential  diag- 
nosis of  these  two  diseases  is,  that  typhus  fever  is  sudden 
in  its  advent,  while  typhoid  fever  comes  on  insidiously,  and 
is  slowly  developed.  In  the  majority  of  cases  of  the  former 
disease  there  is  a  chill  at  the  commencement,  and  severe 
pain  in  the  head,  whereas  in  the  latter  there  is  only  a  chilli- 
ness, some  aching  in  the  limbs,  and  a  slight  headache. 
Muscular  prostration  and  progressive  muscular  weakness 
appear  earlier  and  are  much  more  marked  in  typhus  than 
in  typhoid. 

Second. — The  range  of  temperature  in  the  two  forms  of 
fever  greatly  differs.  For  example,  in  typhoid  fever  we 
commence  on  the  first  day  with  a  slight  rise  in  temperature, 
which  continues,  with  morning  remissions  and  evening 
exacerbations,  until  the  end  of  the  first  week,  when  it  has 
reached  its  highest  point ;  during  the  second  week  it  re- 
mains at  about  the  same  degree,  with  only  slight  variations ; 
during  the  third  week  there  are  more  marked  morning  re- 
missions ;  and  by  the  end  of  the  fourth  week  the  tempera- 
ture has  reached  its  normal  standard. 

In  typhus  fever,  the  temperature  rises  rapidly,  and  before 
the  end  of  the  second  day  reaches  104°  F.  or  105°  F. 
Whatever  degree  is  reached  on  the  third  day  may  be  re- 
garded as  the  maximum  temperature  ;  after  this  time  there 
are  slight,  in-egular  variations  until  the  tenth  or  twelfth 
day,  when  the  temperature  begins  to  fall,  and  rapidly  reaches 
the  normal  standard. 


DirFKKKXTIAL    IHAOXOSIS.  2:"57 

T/{ird.—Thi.':iv  two  f(.iiiis  of  frv.-r  dilTcr  \ovy  ni:nk-'<lly  as 
re<2;ar(ls  the  «'ru])tiou. 

In  typhus  rcvn-  thr  .Tuiiiiuu  makes  its  appearance  upon 
tilt'  lifth  ov  sixth  clay  ;  whih.'  the  enii)tion  of  tyi)hoi(l  fever 
makes  its  ai)i)t'araiice  between  th»»  seventh  and  ninth  day  of 
the  fever.  The  erujition  of  tyjihns  ajtpears  ujfon  the  arms 
and  eliest,  and  more  or  less  over  tlie  entire  body  ;  whereas 
the  eruption  of  t3'phoid  a])pears  upon  the  chest  and  abdo- 
men, very  rarely  upon  the  extremities  ;  sometimes  it  aj)- 
jiears  ni>on  the  loins  when  it  cannot  be  found  on  any  otlier 
part  of  the  body.  As  a  rule,  the  spots  in  typhus  are  nu- 
merous ;  while  in  typhoid  they  are  not  very  abundant. 

In  typhus  fever,  at  first  the  spots  are  small,  slightly  ele- 
vated, of  a  dark  pinkish  hue,  and  disappear  only  on  lirm 
pressure.  As  the  disease  advances  they  become  darker, 
and  linally  are  not  affected  by  firm  pressure  and  remain 
visible  from  the  time  of  their  appearance  until  death  occurs 
or  convalescence  is  established.  In  typhoid  fever  each 
spot  is  rose-colored,  slightly  elevated,  and  disai)pears  on 
slight  pressure.  Each  spot  remains  visible  for  tliree  da^^s 
and  then  disappears,  to  be  followed  by  another  crop.  Usu- 
ally, the  eruption  is  visible  about  two  weeks,  and  when  it 
disai>pears  leaves  the  skin  unstained,  whereas  in  typhus  the 
eruption  disappears  and  leaves  a  stain  upon  the  surface. 
There  is  a  mottling  of  the  surface  in  tyi)hus  fever  which  is 
not  seen  in  typhoid,  and  has  been  described  as  the  i/iul- 
herry  rash. 

It  would  seem  as  though  a  differential  diagnosis  might  be 
as  easily  made  between  the  eru])tion  of  these  two  forms  of 
fever  as  between  the  eruption  of  measles  and  that  of  scarla- 
tina. There  ma}^  be  cases  which  will  cause  you  to  hesitate 
as  regards  diagnosis,  but  wlien  the  eruption  is  developed 
there  need  be  no  (.question  as  to  which  form  of  fever  it  be- 
longs. 

Fourth. — The  brain  symptoms  in  these  two  diseases  also 
differ.  In  tyi)hus  fever  they  api»ear  early,  and  the  head- 
ache and  delirium  are  more  Intense  than  in  ty])hoid.  Deli- 
rium in  tyjilioid  more  commonly  appears  at  the  end  of  the 
second  or  during  the  thiid  week  of  the  disease  ;  whereas  ill 


238  TYPHUS   FEVEK. 

typlms  it  appears  early,  and  before  tlie  end  of  the  second 
week  lias  disappeared  if  recovery  is  to  take  place. 

Fifth. — As  a  rule,  in  typhus  fever  constipation  is  present, 
and  you  will  be  obliged  to  make  use  of  some  mild  cathartic 
in  order  to  move  the  bowels  ;  whereas  in  typhoid  fever  diar- 
rhcEa  is  one  of  the  prominent  symptoms. 

Tympanitic  distention  of  the  abdomen,  gurgling,  and  ten- 
derness in  the  right  iliac  fossa3,  and  perhaps  intestinal 
hemorrhage,  are  all  phenomena  of  typhoid  fever,  but  are 
never  present  in  t^'phus  fever. 

^/^^7i.— Another  point  in  differential  diagnosis  relates  to 
the  duration  of  the  fever,  and  here  we  have  a  marked  differ- 
ence. 

In  tj'phus  fever,  usually  convalescence  will  be  established 
before  the  end  of  the  second  week  ;  some  say  the  tenth  is 
the  critical  day,  but  I  think  it  may  be  any  day  between  the 
eighth  and  fourteenth.  The  average  duration  of  typhus 
then  may  be  regarded  as  fourteen  days  ;  whereas  in  typhoid 
fever  the  average  duration  is  from  twenty-one  to  thirty 
days ;  twenty-one  the  minimum,  and  thirty  the  maximum 
number  of  days. 

>Sfe?)d?i^7i.— Typhus  fever  is  contagious  ;  typhoid  fever  is 
non-contagious.  Typhus  fever  is  due  to  an  animal  poison  ; 
typhoid  fever  is  due  to  an  animal  poison  developed  in  con- 
nection with  vegetable  decomposition. 

The  fact  that  one  is  contagious  and  the  other  non-con- 
tagious renders  the  differential  diagnosis  of  great  importance. 

Elglitli. — When  we  come  to  the  pathological  lesions,  and 
consider  the  manner  in  which  death  occurs  in  these  two 
forms  of  fever,  we  readily  see  how  widely  they  differ. 

The  characteristic  pathological  lesions  of  typhoid  fever 
are  the  changes  which  take  place  in  the  intestinal  glands, 
such  as  ulceration  or  tendency  to  ulceration.  In  all  cases 
these  characteristic  lesions  are  present. 

Suppose  3^ou  have  a  case  of  what  you  have  called  typhoid 
fever,  and  you  follow  it  to  the  dead-house,  but  do  not  find 
ulceration  or  evidences  of  a  tendency  to  ulceration  of 
Peyer's  patches,  then  you  may  be  quite  sure  that  you  have 
made  a  mistake  in  diagnosis. 


Tf,  oil  llir  ollhT  liaiid,  voii  li:iv<'  :i  case  of  su|)})os('(l 
typhus  fcNcr.  ;i!i(l  you  I'dllow  ii  lo  i  lie  (Iriid-housc,  and  liiul 
iilct'ialioii  of  Tcyi  r's  it;itfli«-s,  you  iu:iy  be  eciiially  ct'i'taiii 
that  you  have  iiKuh'  a  iiiisiakf,  niul  tliat  you  liave  hccu 
treating:  a  ('as«»  of  I yplioid,  and  iiol  lyjihus  fever. 

The  ])ari'iichymatous  chiiimcs  wliirh  ar<'  coiunioii  to  lioth 
diseases  have  aheady  been  sulHcit'iii  |y  roiisiih-ird. 

LastJij. — Tyjihus  fever  is  i;"eiiei'ally  e])i(h'iuic  ;  t\]ihoid  is 
always  endeniic.  lu  regard  to  the  ])rotectioH  wliich  one 
attack  of  ty])]ius  fever  furnishes  a<i:aiiist  a  second  attack,  it 
very  markedly  dilb-rs  Trom  typlioid  fever.  One  niny  liave 
typhoid  fever  whenever  the  system  has  been  expose(l  to  tlie 
tyjihoid  poison;  but  one  attack  of  ty})hus  is  almost  a  cer- 
tain protection  against  a  second  attack. 

PiiOGXOSis. — The  prognosis  in  this  disease  is  always 
grave,  and  should  not  be  given  until  you  have  very  care- 
fully considered  all  the  points  in  each  case:  such  as  the 
age  of  the  ])atient,  the  character  of  the  epidciiiic.  and  the 
tendemy  to  certain  com})lications.  In  all  e])idemics,  the 
majority  of  cases  will  nn-over.  The  ratio  of  mortality  as 
given  Ity  dill'erenr  writers,  varies  fioiii  om^  death  in  hvo 
cases  to  one  death  in  sixteen  cases.  The  surroundings  of 
each  patient  should  be  carefully  noted,  also  the  hygienic 
intluences  which  he  is  under,  and  his  habits  of  life  should 
])e  taken  into  account.  With  the  intemperate  the  disease  is 
likely  to  prove  fatiil.  Some  of  the  circumstances  which 
increase  the  danger  in  :iiiy  i)articular  case  are,  a  debilitated 
condition  of  the  })atient  from  advanced  age,  intenqierat*? 
habits,  privation,  and  previous  diseast^  ;  mental  dt'])ression, 
presentiment  of  death,  and  over  crowding  and  bad.  ventila- 
tion ;  a  gouty  diathesis  is  always  dangerous.  Death  may 
occur  in  tyi)hus  fever  from  thi>'e  general  causes  : 

Fh'fii. — From  coma.  This  is  the  result  of  ovei  wli.'lming 
the  system  with  ty])hus  })oison.  The  ])atient  does  not  die 
from  the  effect  of  a  prolonged  high  t«'mj)erature,  nor  from 
complication,  but  dies  as  i)atients  die  in  acute  uraemia, 
because  the  system  is  overwhelmed  by  the  typhus  poison, 
and  the  functions  of  organic  life  are  arrested  by  its  action 
on  the  nerve-centres. 


240  TYPHUS   FEVER. 

Second.— J) eat\i  may  occur  from  syncope  due  to  heart 
failure,  whether  the  heart  failure  is  the  result  of  the  pro- 
longed high  temperature,  or  the  direct  action  of  the  typhus 
poison.  A  continued  temperature  of  105°  F.  or  106°  F.  is 
very  liable  to  be  followed  by  fatal  syncope  from  failure  of 
heart  power,  although  the  evidences  of  parenchymatous 
degeneration  of  the  heart  may  not  be  present. 

^/^/^yZ.— Death  may  occur  from  complication. 

Let  us  now  study  in  detail  the  individual  symptoms  and 
signs  which  render  the  prognosis  unfavorable. 

A  imlse  of  more  than  120  per  minute,  continuing  a  num- 
ber of  days,  intermittent,  and  sometimes  irregular,  bespeaks 
an  unfavorable  prognosis. 

A  hurried  and  difficult  respiration,  with  turgidity  of  the 
face,  due  either  to  cerebral  or  pulmonary  oedema,  renders 
the  prognosis  unfavorable. 

Delirium  which  is  very  active  and  accompanied  by  great 
muscular  prostration,  as  indicated  "by  subsultus,  slipping 
down  in  the  bed,  and  accompanied  by  that  condition  known 
as  "  coma  vigil,"  lasting  for  a  number  of  days,  is  almost  a 
certain  indication  of  a  fatal  termination. 

The  "  pin-hole  pupil  "  mentioned  by  the  old  writers  is  an 
unfavorable  omen.  It  does  not  necessarily  indicate  the 
presence  of  meningitis,  as  was  once  supposed.  Great  mus- 
cular prostration  at  the  very  onset  of  the  disease  renders 
the  prognosis  unfavorable. 

Marked  impairment  of  the  special  senses,  accompanied  by 
very  great  rapidity  of  the  pulse,  is  an  element  of  unfavor- 
able prognosis. 

The  more  abundant  and  the  darker  colored  the  eruption, 
especially  if  accompanied  by  petechial  spots,  the  more  un- 
favorable the  prognosis.  In  children  the  eruption  is  lighter 
in  color  than  it  is  in  adults,  presenting  an  appearance 
similar  to  the  typhoid  eruption.  In  adult  cases,  where 
there  is  dark  mottling  of  the  surface  confined  to  the  ex- 
tremities, with  evidences  of  blood  extravasation,  indicated 
by  the  presence  of  petechise,  your  prognosis  must  be  un- 
favorable, but  the  case  is  by  no  means  hopeless. 
A  dry,  brown,  retracted,  tremulous  tongue  is  seen  only  in 


riKxiNosis.  241 

sovorc  cases.  A  lon.sx-contiiuK'd  lii.irli  t<'in]v'ratiin>  is  always 
an  niirav<)ral»l('  syiiii>t»)ni.  (in-at  (liiniiiutioii  in  tlic  (iuantity 
of  uriiK'  is  an  unfavoiaMf  symitl<»ni,  as  is  also  th»»  i)resence 
of  casts  and  all)nnirn  in  tlh'  niinc.  Itrtcntion  of  urine  is  a 
nioiv  unfavoialilt'  syniittoin  tlian  incontiiifnce  of  urine  ; 
convulsions  and  coma  an-  liaMr  to  follow  such  retention. 

You  must  renu'inber  that  in  tyi)hus  ffver,  more  than  in 
anv  <»ther  disease,  the  ])ati('nt  may  ])ass  into  an  a]»i»arently 
liojH'less  condition,  and  alieiwanls  rally  and  recover.  A 
patient  who  sei'nis  to  be  overwhelmed  with  the  poison,  who 
has  '-conui  vigil,''  "pin-hole  jjupils,"  rolling  of  the  tongue, 
and  a  feeble,  irregular,  but  intermitting  pulse,  may  recover, 
although  these  symptoms  warrant  an  unfavorable  i)rognosis. 

"Coma  vigil,"  more  tliau  any  single  sym])tom,  warrants 
an  unfavorable  prognosis. 

Thi^  first  indicution  of  recovery  is  a  diminution  in  the  fre- 
quency of  the  pulse.  The  pulse  may  have  been  120,  but  on 
the  tenth,  twelfth,  or  fourteenth  day,  it  begins  to  diminish 
in  frequency.  The  tongue  has  been  brown  and  dry,  sub- 
sultus  and  delirium  may  have  been  present,  even  "coma 
vigil"  may  have  manifested  itself ;  there  has  been  great 
muscular  jn-ostration  ;  the  patient,  attem])ting  to  rise  from 
the  bed,  may  have  fallen  upon  the  Hoor  ;  now,  the  pulse 
begins  to  get  slower,  the  patient  falls  into  a  refreshing  sleep 
and  awakes  perfectly  conscious  ;  his  countenance  is  changed 
from  the  dusky  hue  to  an  almost  natural  api)earance,  and 
he  desires  food.  In  other  words,  within  twenty-four  hours 
an  entire  change  comes  over  the  patient,  and  that  change  is 
first  indicated  by  a  diminution  in  the  frequency  of  the  i)ulse, 
accompanied  by  a  fall  in  temi)erature.  The  fall  in  tempera- 
ture is  not  extreme;  perhai)s  a  fall  of  two  degrees  is  first 
noticed. 

My  experience  goes  to  show  that  there  is  an  attemjit  at 
convalescence  npon  the  eighth  day  of  the  fever.  Especially 
in  those  cases  that  recover,  u])on  that  day  you  will  notice 
a  slight  fall  in  temperature,  although  the  temperature  may 
again  rise  ;  upon  the  twelfth  or  fourteenth  day  there  is  a 
distinct  fall  in  tem])eratureand  diminution  in  the  fre(piency 
of  the  ])ulse  that  is  indicative  of  convalescence. 
IG 


242  TYPHUS   FEVER. 

The  mode  of  recovery  in  these  two  forms  of  fever,  typhus 
and  typhoid,  is  perhaps  tlie  most  distinguishing  clinical 
feature.  In  typhus,  recovery  is  rapid  ;  while  in  typhoid  it 
is  markedly  slow. 

Of  all  the  conditions  which  influence  the  prognosis  in  ty- 
phus fever,  age  and  tlie  liahits  of  the  patient  have  as  great, 
if  not  greater,  influence  than  any  other.  I  am  convinced  of 
this  from  an  experience  in  the  care  of  typhus  fever  patients 
which  dates  back  almost  to  the  very  commencement  of  my 
study  of  medicine,  for  very  early  did  I  have  the  care  of  a 
typhus  fever  ward. 

In  children,  typhus  fever  is  a  very  simple  form  of  disease. 
The  rate  of  mortality  is  very  low.  I  remember  having  the 
care  of  sixty  children  with  typhus  fever,  and  among  these 
only  one  death  occurred.  This  is  as  low  a  rate  of  mortality 
as  you  can  expect  in  measles. 

When  the  patient  has  passed  the  middle  period  of  life, 
there  is  great  danger  from  typhus  fever.  So  with  the  in- 
temperate, and  those  who  have  lived  amid  unfavorable  hy- 
gienic surroundings. 

The  bright,  educated  person,  the  one  with  an  active  brain, 
is  less  likely  to  recover  than  is  the  stupid,  uneducated  one. 
For  example,  the  hod-carriers  may  have  the  worst  type  of 
typhus  fever,  and  pass  through  it  with  safety,  stupid  when 
they  contract  the  disease,  and  stupid  when  they  get  well. 
Let  a  man  with  an  active  brain  contract  the  disease,  and  the 
'■'' coma  mgiV  comes  on,  the  imagination  is  vivid;  failure 
of  heart  power  is  present  early,  and  death  is  almost  certain 
to  follow. 


LECTURl]    XXI. 


TYPHUS  FEVER. 

Trent  iiirnt. 


I  HAVE  already  completed  the  history  of  typhus  fever, 
with  the  exception  of  its  treatment,  and  now  invite  atten- 
tion to  the  more  prominent  measures  which  have  been  and 
now  are  employed  in  its  management.  You  will  notice  that 
in  many  respects  these  measures  are  similar  to  those  pro- 
posed for  the  management  of  typhoid  fever  patients,  yet  the 
treatment  of  these  two  diseases  differs  in  certain  essential 
particulars.  When  the  symptoms  are  mild,  very  simple 
measures  are  all  that  is  required.  Of  these,  confincincut  to 
bed,  cooling  drinks,  mild  aperients,  a  milk  diet,  and  free 
ventilation  are  tlie  chief,  and,  indeed,  all  that  is  required. 
It  is  alsi)  important  to  observe  the  sam(>  rules  in  regard  to 
tln'  arrangement  of  tlie  sick-room  \vlii(  li  were  recommended 
in  the  case  of  typhoid  fever  patients.  Tlie  more  perfect  the 
ventilation,  the  great«'r  the  atnouiit  of  fresh  air  around  the 
patient,  the  better  his  chances  for  recovery. 

The  majority  of  cases  of  typlius  fever  are  usiiered  in  by 
active,  and  severe  symptoms,  such  as  would  tempt  one  to 
adopt  a  vigorous  plan  of  treatment — symptoms  which  at 
one  time  were  thouirht  to  indicate  the  employment  of  lieroic 
antiphlogistic  measures.  You  must  remember  that  these 
active  symptoms  are  due  to  the  effect  produced  on  the  ner- 
vous system  by  a  jioison  contained  in  tin*  circulating  blood, 
and  that  this  cannot  be  eliminated  by  any  means  of  which 


244  TYPHUS   FEVER. 

we  have  any  accurate  knowledge,  certainly  not  by  vomit- 
ing, purging,  sweating,  or  bleeding.  AVitli  these  symptoms 
there  is  great  prostration  of  the  vital  powers  and  a  rapid 
metamorphosis  of  tissue.  Although  the  symptoms  seem 
urgent,  and  the  patient  has  a  flushed  face,  a  rapid  pulse, 
congested  conjunctivae,  and  a  high  temperature,  not  a  sin- 
gle measure  must  be  resorted  to  which  has  a  tendency  to 
diminish  the  vitality  of  your  patient.  Dr.  Tweede,  of  Lon- 
don, states,  as  the  summing  up  of  his  experience  upon  tins 
point,  that  although  at  one  time  he  supposed  bleeding  and 
the  so-called  antiphlogistic  remedies  were  necessities  in  the 
treatment  of  typhus  fever,  yet  for  the  past  ten  or  fifteen 
years  he  has  not  seen  a  single  case  in  which  depletive 
measures  were  admissible. 

Writers  upon  this  disease  usually  consider  its  treatment 
under  two  heads— the  preventive  and  curative.  I  prefer  to 
use  the  terms  prophylactic  and  remedial  or  medicinal,  for  I 
question  our  ability  to  cure  disease. 

You  can  do  much  to  prevent  the  development  of  many 
diseases,  and,  as  guardians  of  the  public  health,  this  will 
constitute  an  important  part  in  the  active  labor  of  your  pro- 
fession. 

How,  then,  can  you  prevent  the  development  of  typhus 
fever  %  Medical  skill  cannot  prevent  the  importation  of  the 
disease  into  localities  where  it  is  not  indigenous.  This  is 
beyond  the  power  of  medical  men,  for  it  is  controlled  by 
state  and  national  authority.  Consequently  typhus  fever 
will  probably  continue  to  be  imported  into  districts  where  it 
does  not  originate. 

For  example,  we  shall  occasionally  see  the  disease  in  tliis 
city;  it  may  appear  in  any  of  our  commercial  seaports, 
and  from  them  it  may  be  carried  into  the  interior.  Yet  we 
can  do  much  to  prevent  its  spread  after  it  is  imported,  and 
can  prevent  its  development  as  an  epidemic  when  it  is  car- 
ried into  any  locality  in  the  interior.  It  is  important  that 
the  flrst  case  or  cases  of  typhus  fever  which  are  developed 
in  any  locality  should  be  closely  watched.  They  should  be 
immediately  quarantined.  The  dwellings  in  which  the  fever 
has  broken  out  should  be  depopulated,  that  is,  in  a  tene- 


TKKATMKNT.  21.1 

incnt-lioiist'  in  wliicli  the  ffvcr  has  iiiadc  its  ri])])(>ai:m('<',  all 
the  ramilii'S  shoiikl  be  removed,  and  the  house  should  Ix' 
thoroughly  disinfected.  The  disiiir.'ctioii  must  l)e  ihoiou-li. 
not  for  a  few  houi-s,  hut  foi-  one  or  two  days,  and  afterwards 
the  house  should  remaiu  open  for  tlu;  free  circulation  of  air 
for  a  considerable  length  of  time  before  persons  shouhl  be 
allowed  to  again  inhabit  the  rooms.  Before  we  conclude 
the  subject  of  treatment  you  will  see  the  importance  of 
following  these  directions. 

If  typhus  fever  occurs  in  the  dAvellings  of  the  wealthy, 
tlieir  houses  must  be  quarantined.  All  persons  must  be 
prevented  from  visiting  them,  and.  all  persons  within  the 
dwelling  must  be  prevented  from  going  abroad.  After  the 
sick  have  recovered,  there  must  be  the  same  thorough  disin- 
fection as  in  the  tenement  house. 

All  these  regulations  must  be  as  carefully  observed  among 
the  rich  as  among  the  poor.  It  is  the  rule,  that  though  a 
person  may  be  well  fed,  well  clothed,  and  well  housed,  and 
be  ever  so  cleanly,  yet  if  brought  in  contact  with  the  ])oi- 
son  of  typhus  fever  for  a  sufficient  length  of  time  he  will 
contract  the  disease. 

Usually,  in  epidemics  of  typhus  fever  there  are  certain 
foci  from  which  the  dis(^ase  spreads.  Perhaps  the  points 
from  which  the  contagion  more  especially  emanates  are 
within  an  area  of  half  a  mile  square,  and  yet  the  disease 
may  have  lieen  prevailing  for  two,  three,  or  even  four 
months.  Under  such  circumstances  it  is  possible  to  ])revent 
the  spread  of  the  fever  by  the  means  just  indicated. 

As  far  as  its  manag(Mnent  in  iios])itals  is  concerned,  I 
would  say  you  sliould  never  undertake  it  within  brick  or 
stone  enclosures.  If  possible,  patients  should  be  ]>laced  in 
lu-oad  ])avilions  or  tents,  so  that  the  largest  ])ossible amount 
of  fresh  air  shall  be  in  circulation  about  them.  It  is  not 
sufficient  to  have  free  ventilation  in  t  h--  ordinary  acce])talion 
of  that  tei-m.  The  opening  of  a  window  will  not  ac('om])lish 
the  desired  result.  Remove  all  the  windows  in  a  room,  re- 
gardless of  the  cold,  and  cover  the  ])atienis  with  a  >n(licieut 
nundier  of  l)lankets  to  ke-.'])  them  warm.  Allow  fnsli  air  to 
surround  them. 


246  TYPHUS   FEVEE. 

There  are  certain  conditions  wliicli  predispose  to  the  de- 
velopment of  typhus  fever,  such  as  the  conditions  caused 
by  interference  with  nutrition,  by  want  of  cleanliness,  bad 
ventilation,  want  of  food,  and  habits  of  intemperance. 

In  Ireland,  when  famine  occurs,  then  the  people  suffer 
most  from  typhus  fever  ;  then  it  prevails  as  an  epidemic. 
When  it  prevails  epidemically  in  Ireland,  then  we  aie  al- 
most certain  to  receive  a  certain  number  of  cases  in  New 
York. 

Fatigue,  anxiety,  and  anything  which  tends  to  lower  the 
vitality  of  an  individual  render  him  susceptible  to  the  in- 
fluence of  typhus  fever  poison.  Remember  this,  and  also 
what  I  have  before  told  you  in  regard  to  eating  before  you 
enter  a  ward  filled  with  typhus  fever  patients. 

When  the  typhus  fever  manifests  itself  you  can  now 
understand  how  important  it  is  that  the  guardians  of  the 
poor  should  not  only  enforce  cleanliness,  but  that  they 
should  feed  the  poor  better  than  at  other  times.  If  cleanli- 
ness is  observed,  the  dwellings  thoroughly  disinfected,  and 
the  poor  well  fed,  the  most  virulent  epidemic  can  soon  be 
stayed.  The  effects  produced  by  such  measures  are  some- 
times wonderful. 

In  the  year  1861,  at  the  commencement  of  the  epidemic, 
when,  as  I  have  before  stated,  the  first  case  occurred  in  a 
tenement-house  in  one  of  our  down- town  streets,  it  was  six 
weeks  before  it  spread  from  that  locality.  The  spread  of 
the  fever  should  have  been  stopped  at  that  point ;  but  very 
little  attention  was  paid  to  it,  and  it  began  to  spread  from 
one  point  to  another,  until  some  six  or  seven  thousand  cases 
were  developed.  Many  of  our  prominent  citizens  sickened 
with  the  fever  and  died.  This  epidemic  could  have  been  pre- 
vented had  measures  been  taken  early  to  prevent  the  spread 
of  the  disease.  It  seemed  to  me  that  our  city  authorities 
were  responsible  for  a  large  proportion  of  the  deaths  which 
occurred  during  the  prevalence  of  that  epidemic. 

We  now  come  to  the  medicinal  treatment  of  this  disease. 

Medicinal  Teeatment. — As  I  have  already  stated,  medi- 
cines are  powerless  either  to  arrest  the  j)rogress  or  shorten 
the  duration  of  this  fever. 


TUKAl'MKNT.  247 

Tlie  iirst  point  wliicli  I  sli.-ill  discuss  iiiultM-  tliis  lifui"!  re- 
lates to  iKMitraliziiii!;  the  jxtisoii.  This,  many  authors  chiim, 
can  be  doiif,  ami  tlie  progress  of  the  disease  thus  be  ar- 
rested. In  my  own  experience  I  have  found  no  medicinal 
agent  wliich  can  neutralize  or  destroy  ty])lnis  ])oison,  or 
wliicji  has  powei-  to  arrest  the  progress  or  shorten  the  dura- 
tion of  tliis  fevtr.  DiU'ereut  remedial  agents  liav»'  been  i)ro- 
posed  for  the  acconiplishTueiit  of  this  result,  aceoiding  to 
the  views  held  in  regard  to  the  nature  of  the  t3-phus  poisc^n, 
and  its  effects  upon  the  system. 

At  one  time  the  mineial  acids  wei-e  supposcr'd  to  possess 
this  power,  and  were  administered  for  that  ])ur])o<e  ;  ])ut,  at 
the  present  time,  they  have  fallen  into  disuse.  The  inteinal 
use  of  carbolic  acid,  chlorine  water,  creasote,  and  more  re- 
cently salicylic  acid  has  been  recommended  for  the  same 
])urpose.  The  inhalation  of  ox3'gen  gas  has  also  been 
thought  to  be  of  service  in  arresting  the  blood-changes,  and 
thus  preventing  the  poison  from  having  its  customary 
effect  upon  the  system.  By  the  stimulation  whicli  it  pro- 
duces, the  patient  may  be  brought  out  of  an  apparent  state 
of  coma,  and  revive  in  a  marked  degree  ;  but  the  relief  is 
only  tem])orary.  For  a  time  the  patient  may  improve,  his 
consciousness  return,  and  his  appearance  indicate  that  con- 
valescence is  established ;  but  his  unfavorable  symptoms 
will  return,  and  it  will  become  quite  evident  that  the  oxygen 
has  not  neutralized  the  typhus  poison. 

It  seems  to  me  that  fresh  air  is  the  only  thing  which  has 
power  to  neutralize  the  poison  of  tyj^ius  fever.  It  certainl}- 
possesses  this  power  when  exti-rnal  to  the  body.  For  ex- 
ample: place  a  patient  sick  with  typhus  fever  in  a  well- 
ventilated  board  pavilion,  or  in  a  tent  where  an  abundance 
of  fresh  air  can  circidate  about  him,  and  it  is  almost  impos- 
sible for  him  to  communicate  the  disease  to  a  healthy 
person.  Again,  place  a  patient  in  a  closed  room,  perhaps- 
twelve  by  fourteen  feet  square,  let  a  health}^  person  remain 
with  him  a  single  night— probably  a  much  sliorter  time  is 
sufficient — and  the  latter  will  be  almost  certain  to  contract 
the  disease.  Why  is  the  disease  more  readily  communi- 
cated in  the   one  case  than   in  the   others     Certainly  tke 


248  TYPHUS   FEVEK. 

fresli  air  which  circulated  about  the  typhus  fever  patient 
must  liave  prevented  contagion.  Fresh  air,  when  inhaled, 
produces  to  a  greater  or  less  extent  the  same  effect.  You  may 
say,  how  do  we  know  this  ?  It  is  known  as  a  clinical  fact. 
I  have  seen  a  typhus  fever  patient,  who  was  apparently 
overwhelmed  by  the  poison— perhaps  within  forty-eight 
hours  from  the  commencement  of  the  attack  was  in  a  state 
of  coma,  with  high  temperature,  a  rapid  pulse,  etc.,  and  all 
the  symptoms  indicating  that  he  was  fast  succumbing  to 
the  disease— when  brought  from  a  crowded  tenement- 
house  and  placed  in  a  tent,  where  he  could  inhale  plenty  of 
fresh  air,  within  four  or  five  hours  from  the  time  of  admis- 
sion begin  to  rally,  and  go  on  to  recovery.  Fresh  air  was 
the  only  remedial  agent  employed. 

If  fresh  air  does  not  neutralize  the  poison,  it  certainly  has 
some  effect  in  eliminating  the  poison,  and  thus  mitigating 
the  severity  of  the  fever,  and  perhaps  shortening  its  dura- 
tion. If  you  choose,  you  may  regard  it  as  a  remedial 
agent,  for  it  certainly  is  of  greater  value  than  any  so-called 
remedial  agent  at  our  command. 

To  accomplish  the  best  results,  place  three  or  four  pa- 
tients in  a  tent  twenty  feet  square;  the  fly  of  the  tent 
should  be  thrown  up,  and  if  the  weather  is  cold,  your 
patient  should  be  well  covered  with  blankets.  By  this 
means  you  will  insure  all  the  advantages  of  free  ventilation. 

The  question  now  arises,  what  therapeutical  agents  can 
be  employed  with  advantage,  in  order  to  accomplish  the 
desired  results  1  The  following  are  of  the  greatest  im- 
portance : 

First. — The  reduction  of  temperature. 

Second. — The  sustaining  of  heart  power. 

The  former  is  of  as  great  importance  in  typhus  as  in 
typhoid  fever,  and  the  same  rules  should  govern  you  with 
regard  to  the  agents  to  be  employed,  and  the  mode  of  their 
employment. 

As  in  the  management  of  typhoid,  so  in  the  management 
of  this  fever,  we  have  two  antip}T:'etic  agents,  namely,  the 
sulphate  of  quinine  and  the  application  of  cold  to  the  sur- 
face.    These  agents  may  be  employed  separately  or  in  con- 


TIIKATMKN'T.  2-19 

jnnrtioii.  I  would  Ikmc  rt'])t>;ir  a  statciiit'iit  alivndy  mad**, 
tliat  1  ht'lleve  quiniiif  to  l)t*  tlu'  more  i)o\v('rriil  antipyretic 
of  tlie  two  argents. 

You  will  find  that  tlic  temperature  rises  more  quickly  in 
ty])hus  than  in  typhoid,  after  it  has  l)een  reduced  l>y  l\u; 
cold  bath,  and  all  through  the  early  jtari  of  the  fever  you 
will  be  (»bli<::ed  to  resort  to  the  bath  much  mon;  frequently 
than  in  typhoid. 

The  mh's  for  the  administration  oC  the  baths  in  lyjihns 
fever  diifer  somewhat  from  those  that  govern  you  in  ty  ])hoid. 

In  typhus  fever,  as  soon  as  the  temperature  of  the  patient 
rises  to  104°  F.,  he  must  be  placed  in  a  bath  the  tempera- 
ture of  which  is  about  ten  degrees  below  that  of  the  patient ; 
gradually,  by  the  addition  of  ice  or  ice- water,  bring  the  tem- 
perature* of  the  bath  down  to  68^  F.  or  70°  F.  The  patient 
must  be  kept  in  the  bath  until  his  temperature  falls  to  101° 
F.  or  10"2°  F.,  then  taken  out,  quickly  dried  and  placed 
in  bed.  For  some  time  after  the  removal  from  the  bath, 
the  axillary  temperature  will  continue  to  fall,  as  the  trunk 
parts  with  heat  to  the  extremities.  As  soon  as  the  tem- 
perature rises  again  to  104°  F.,  the  patient  must  receive 
another  bath.  If  the  patient  is  suffering  with  intense  pain 
in  the  head,  or  is  actively  delirious  during  the  bath,  ice-bags 
may  often  be  ap])lied  to  the  head  with  benefit. 

If  the  cold  baths  do  not  readily  reduce  the  patient's  tem- 
perature, or  if  the  fall  is  of  short  duration,  antipyretic 
doses  of  quinine  must  be  administered,  according  to  the 
rules  given  for  its  administration  in  the  treatment  of  typhoid 
fever. 

As  soon  as  you  have  passed  the  first  week  of  the  disease, 
having  kept  the  patient's  temperature  below  103°  F.,  usu- 
ally it  will  not  be  necessary  or  advisable  to  continue  the 
l)aths.  In  most  cases  antipyretic  doses  of  quinine  will  l)e 
found  sufficient  to  keep  down  the  temperature,  JVoio,  if  not 
l)efore,  there  will  be  evidem'e  of  h(\art  failure,  and  the 
question  presents  itself.  Shall  alcoholic  stimulants  beadmin- 
istered?  In  tliis  connection  1  will  mention  tlie  rules  which 
have  governed  the  profession  in  the  administration  of  stim- 
ulants in  ty])hu<  f<'ver. 


250  TYPHUS   FEVER. 

The  liistory  of  alcoholic  stimulants  in   the  treatment  of 
typhus  fever  dates  back  about  forty  years,  to  the  teachings 
of  Graves  andStokes,  since  which  time  until  quite  recently 
tliey  have  constituted  an  important  element  in  the  treat- 
ment of  this  fever,  receiving  the  approval  of  almost  the  en- 
tire profession.     Even  at  the  present  day  the  habit  of  ad- 
ministering alcohol  in  large  quantities  in  fever,  and  not 
unfrequently  in  an  injudicious  manner,  has  become  almost 
universal.     Most  writers  have  regarded  a  frequent  feeble 
pulse,  with  feeble  cardiac  impulse,   even  though  cerebral 
symptoms  may  be  present,  as  certainly  indicating  the  ad- 
ministration of  alcoholic  stimulants.     The  directions  were, 
to  commence  their  administration  early,  and  in  sufficient 
quantities  to  control  the  pulse.     It  was  thought  that  the 
earlier  their  administration  commenced,  the  better  the  chance 
for  recovery,  as  the  failure  of  heart  power,  which  makes  its 
appearance  in  the  later  stages  of  typhus,  would  be  pre- 
vented.    iSTo  limit  was  given  as  to  the  quantity  to  be  ad- 
ministered; and  when  typhus  fever  was  treated  in  Belle vue 
Hospital,  not  unfrequently  it  was  forty  or  fifty  ounces  of 
whiskey  administered  in  divided  doses  within  twenty-four 
hours. 

The  object  to  be  accomplished  was  control  of  the  pulse. 
This  could  in  most  cases  be  done  for  a  time,  but  as  the  dis- 
ease advanced,  and  the  patient  became  more  and  more  over- 
whelmed by  the  typhus  poison,  alcohol  lost  the  power  of 
giving  force  to  the  pulse.  Under  such  circumstances,  the 
rule  was  to  give  it  ad  libitum,  for  alcohol  was  regarded  as 
the  only  agent  by  which  the  life  of  the  patient  could  be 
saved.  I  remember  administering  from  a  pint  to  a  quart  of 
brandy  to  a  fever  patient  within  twenty-four  hours.  Now, 
what  is  the  effect  produced  by  the  administration  of  large 
quantities  of  alcohol  into  the  system  \ 

After  carefully  studying  for  two  years  the  action  of  alco- 
hol on  typhus  fever  patients,  I  became  convinced  that  in 
some  patients,  if  not  in  all  those  who  were  severely  ill, 
especially  where  there  was  interference  with  the  function  of 
the  kidneys,  its  beneficial  effects  Avere  doubtful,  if  its  action 
was  not  decidedly  injurious.     That  stimulants  will  control 


TUKATMKXT.  251 

llir-|)uls('  and  sustain  the  licarfs  action  for  a  time,  there 
(.•an  be  no  question;  l)ul  1  found  that  in  ail  scviTe  cases 
there  canu'  a  liiiir  wlim  alcnliol.  in  iioucvri'  lai'.i^e  doses  it 
was  •••ivcn,  ei'asrd  to  have  tliis  power.  I'x-sich's,  it  must  he 
renieniber.'d  that  larn-e  (|uaiitities  of  alcoliol  thus  admin- 
istered disinrl)  nuliiiion,  h'ssen  secretion,  i)r('V('iit  tlicrlinii- 
nation  of  mva,  and  tend  to  induce  a  slate  of  c(jnui  whicli 
cannot  n-adiiy  be  distinuuished  from  tliat  induced  ))y  the 
disease  itself;  allofwhicli  imisi  necessarily  greatly  increase 
the  danger  of  ;i  fatal  lennination. 

During  the  prevalence  of  the  last  ei)id('mic  of  typhus  fever, 
I  took  charge  of  the  fever-tents  on  Blackwell's  Island,  with 
tlu>  intention  of  testing  the  effect  of  the  wilhdiawal  of 
stimulants  in  the  treatment  of  typlius  fever. 

In  my  earlier  professional  life  I  was  thoroughly  imbued 
with  the  idea  (for  I  was  ahnost  born  into  the  profession 
from  a  tyjihus  fever  ward)  that  alcohol  was  a  necessity  in 
the  treatment  of  typhus.  My  house  i^hysician,  Dr.  Engs, 
Avho  took  the  immediate  care  of  the  fever-tents  under  my 
direction,  had  had  a  large  experience  in  the  treatment  of 
typhus  fever  in  Bellevue  IIosi)ital,  had  there  contracted  the 
disease,  and  believed  that  his  life  had  been  saved  by  the  free 
use  of  stimulants. 

As  we  assumed  the  charge  of  tln^  tents  I  ordered  that  no 
stimulants  nor  medicines  should  ])e  administered  to  any 
inniatt}  of  the  tents. 

The  cases,  as  they  were  brought  into  the  tents  from  the 
city,  were  of  as  severe  a  type  as  any  wc  had  treated  in  rx'lle- 
vue  nos))ilal ;  sonn*  were  in  a  state  of  coma,  with  an  im])er- 
cejitible  radial  pulse,  and  all  the  signs  of  si)eedy  dissolution, 
—conditions  which  I  had  been  educated  to  regard  as  most 
certainly  indicating  the  free  administration  of  stimulants. 

The  rule  which  I  established  was  faithfully  carried  out 
with  the  following  results :  W  hih-  t  he  fever  was  in  Bellevue, 
the  ratio  of  mortality  was  one  death  in  every  five  ;  and  in 
th<'  tents,  one  in  sixteen.  I  do  not  claim  that  the  great 
diminution  in  the  ratio  of  moitality  in  the  tents,  as  com]  >a  red 
with  that  of  Bellevue  nosi)ital,  wasdu^'  to  the  non-adminis- 
tration of  stimulants  in  the  one  case,  and  their  free  aduiin- 


252  TYPHUS   FEVEPw 

istration  in  the  otlier.  I  do,  however,  most  certainly  affirm 
that  my  experiments  in  tlie  tents  convinced  me  tliat  the 
beneficial  effects  which  had  been  ascribed  to  the  use  of  alco- 
hol in  typhus  fever  were  not  fairly  due  to  it.  Although  I 
would  not  entirely  discard  the  use  of  alcohol  in  the  treat- 
ment of  typhus,  still  I  would  greatly  limit  its  use  and  give 
it  only  as  an  occasional  aid,  to  carry  my  patient  over  some 
peculiar  time  of  danger  from  heart  failure. 

Typhus  fever  patients  under  twenty-five  years  of  age 
rarel}"  require  or  are  benefited  by  alcohol,  unless  they  were 
of  intemperate  habits  prior  to  the  attack.  To  the  old  and 
feeble  its  occasional  administration  may  be  of  great  benefit, 
and  at  times  be  the  means  of  saving  life. 

A  copious  dark  eruption,  with  coldness  of  the  extremi- 
ties, specially  indicates  the  use  of  alcohol. 

As  a  rule,  delirium,  headache,  scanty  urine,  and  intense 
heat  of  surface  contra-indicate  the  use  of  alcohol. 

In  any  case  when  you  decide  to  administer  alcohol,  care- 
fully watch  the  effect  of  the  first  few  doses  ;  the  same  rules 
should  govern  yow  that  were  laid  down  for  the  administra- 
tion of  stimulants  in  typhoid  fever.  It  is  impossible  to  give 
any  positive  instructions  as  regards  the  quantity  of  stimu- 
lants required  in  each  case.  It  is  very  rarely  necessary  at 
any  time  during  the  fever  to  give  more  than  eight  ounces  of 
brandy  during  twenty-four  hours.  If  this  amount  will  not 
sustain  the  heart  power,  I  am  confident  larger  quantities 
will  fail  to  do  it,  and  also  that  such  administration  has 
hastened  the  fatal  issue. 

As  soon  as  the  symptoms,  on  account  of  which  the  alco- 
hol may  have  been  resorted  to,  are  relieved,  the  quantity 
must  be  reduced,  or  its  administration  altogether  stopped. 
I  do  not  altogether  condemn  the  use  of  stimulants  in 
t3-phus  fever,  but  I  do  so  as  regards  stimulants  as  a  plan  of 
treatment ;  and,  where  the  patient  can  be  freely  exposed  to 
fresh  air,  I  doubt  if  their  use  is  often  required. 

To  diminish  the  frequency  of  the  pulse,  when  it  follows 
the  reduction  of  the  temperature  by  the  application  of  cold 
to  the  surface,  and  the  administration  of  quinine  in  anti- 
pyretic doses,  cardiac  sedatives  have  been  employed,  such 


TliHATMKNT.  2.")3 

as  veratruni,  aconite,  uiul  dii;lt:vlis.  The  ra])id  puis*;  in 
t3'i)lius  l\'V('i\  aftt'i-  the  first  onset  of  the  disease,  ol'lfii  is 
not  due  to  the  hi,u-li  t<'iiiii<'ialm<',  l)iil  l<»  i\u-  failiiiv  of  In-art 
power;  when  such  is  the  ease,  digitalis  sh(juld  be  <'iu- 
ployed.  Digitalis  diuiiuishes  the  rretjueiu'y  of  the  i)ulse, 
by  increasing  the  i)t)wer  of  ilir  li<  ait,  and  at  the  same  time 
it  increases  the  secretion  of  urine,  wliich  frequently  is 
scanty,  and  tlius,  to  a  limited  extent,  becomes  an  elimina- 
tive. 

From  four  to  six  drachms  of  thi'  infusion  of  digitalis  may 
often  be  given  with  beneht  during  twenty-four  hours.  If 
the  heart  power  cannot  be  sustained  b}^  the  moderate  use 
of  stimulants  and  by  digitalis  given  as  indicated,  we  are 
helpless  so  far  as  remedial  agents  are  concerned. 

The  treatment  of  the  special  symptoms  of  typhus  fever 
require  only  a  passing  notice. 

The  headache,  when  intense,  is  best  relieved  by  cold 
api)lications  in  the  form  of  ice-bags.  If  it  is  accompanied 
by  intolerance  of  light,  a  blister  to  the  back  of  the  neck 
will  be  found  to  give  relief. 

Sleeplessness  in  any  stage  of  the  disease,  if  it  continues  for 
two  or  three  da^^s,  must  be  relieved,  for  it  is  of  itself  suffi- 
cient to  cause  a  fatal  termination.  If  sleep  does  not  follow 
the  applications  of  cold  to  the  head,  opiates  may  be  ad- 
ministered in  full  doses.  I  have  seen  tyi)hus  fever  patients 
that  had  not  slept  for  forty-eight  hours  drop  into  a  quiet 
slee])  within  a  few  hours  after  they  had  been  exposed  to 
free  ventilation.  (treat  care  should  be  exercised  that  their 
ai»aitni<'nts  are  kei)t  perfectly  quiet  and  darkened.  When 
delirium  and  other  cerebral  s\  in])tonis  are  asso<'iate(l  with 
sleeplessness,  hydrati'  of  chloral  may  be  carefully  employed. 
Stupor  is  to  be  countera<-ted  V)}-  pnjmoting  the  action  of  all 
the  excreting  organs,  applying  external  stiniulanls,  and 
administering  diffusible  stimulants,  the  most  serviceable  of 
which  are  coffe(»,  musk,  and  canq)hor.  In  the  early  stage 
of  the  disease  the  cold  chjuche  may  l)e  t'in]»loye(l. 

Two  remedies  have  been  recoinnnMided  for  the  coma  of 
tyi)hus,  namely,  valeiian  and  i>hos}ihorus ;  neither  of  these 
remedies  have  seemed  to  me  to  be  eilicacious. 


254  TYPHUS   FEVER. 

When  tliere  are  evidences  of  great  prostration  in  connec- 
tion with  any  of  these  sjjecial  sj^nptoms  to  whicli  I  have 
referred,  the  moderate  administration  of  stimulants  may  be 
resorted  to,  and  if  relief  follows  the  first  few  doses  their 
use  may  be  continued. 

In  the  treatment  of  the  complications  which  I  stated  to 
you  were  liable  to  occur  during  the  course  of  typhus  fever, 
you  must  be  guided  by  general  principles  and  by  the  symp- 
toms in  each  individual  case,  never  forgetting  that  the 
primary  disease  has  a  tendency  to  induce  great  nervous 
j)rostration  and  depression,  and  that  the  heart's  action 
forbids  the  use  of  all  depleting  remedies,  and  indicates  a 
supporting  plan  of  treatment. 

The  pulmonary  and  laryngeal  complications,  as  well  as 
erysipelas,  bed-sores,  and  gangrene,  are  to  be  managed  in 
the  same  manner  as  was  proposed  when  they  occur  as  com- 
plications in  typhoid  fever. 

Diet. — This  is  of  primary  importance.  Though  the  pa- 
tient refuse  all  nourishment,  if  possible  he  must  be  required 
or  even  compelled  to  take  it.  As  the  digestive  powers  are 
impaired,  great  care  is  required  in  selecting  and  administer- 
ing the  proper  nourishment,  and  it  must  be  given  at  stated 
intervals,  var^^ing  from  one  to  two  hours.  Care  must  be 
taken  not  to  over-feed — much  harm  may  be  done  in  this  way. 
When  the  patient  clinches  his  teeth  and  obstinately  refuses 
all  food,  or  is  unable  to  swallow,  his  life  may  sometimes  be 
saved  by  pouring  liquid  nourishment  into  the  stomach  by 
means  of  a  long  tube  passed  through  the  nose. 

Milk  best  serves  the  purpose  as  an  article  of  diet.  It  may 
be  given  ice-cold,  if  desired,  and  in  such  quantities  as  the 
stomach  can  receive  and  digest.  If  more  concentrated 
nutrition  is  desirable,  the  yolk  of  eggs  may  be  beaten  up 
and  added  to  the  milk. 

The  management  of  patients  during  convalescence  from 
typhus  fever  is  a  matter  of  very  great  importance. 

As  soon  as  the  fever  ceases,  most  patients  convalesce 
rapidly  unless  there  is  some  complication,  and  the  chief  duty 
of  the  physician  is  to  prevent  premature  exertion  and  ex- 
posure to  cold,  and  to  restrain  the  patient  in  the  gratifica- 


TUl'.A'l'MKNT.  255 

tioii  i)f  ail  inordinate!  ai)i>('tit»'.  At  tliis  time  pot  I.t  or  alo 
may  Itc  (alvi'ii  lo  iiuTcasc  tlif  power  of  assiniilalion.  Tlui 
miiii'ial  aridv.  l*ciu\ian  l>;irk.  and  iron  may  also  be  given  as 
tonics;  these  art'  part  icidarly  ealli-d  I'oi-  when  llu'  ]>ulse  is 
slow  and  feeble. 

It  is  imp(H-tant  to  unard  anaiiist  any  sudd»'n  physical 
eJTort  diirinii-  the  early  jjcriod  of  eonvaleseence,  as  it  may 
lead  to  coagulation  of  blood  in  the  veins.  An  opiate  or 
liydrate  of  chloral  is  sometimes  required  to  ])i()duce  sleep 
during  c()nvales('enc<\ 

III  all  cases  great  beiielit  will  be  derived  from  a  tem- 
poiary  change  of  residence,  and  daily  exercise  in  the  open 
air. 


LECTURE    XXII. 


RELAPSING  FEVER. 

Morbid  Anatomy.  — Etiology.  — Symptoms.  — Differential 
Diagnosis. — Treatment. 

Having  completed  the  history  of  typhus  fever,  I  shall 
this  morning  invite  your  attention  to  the  next  in  the  list  of 
contagious  fevers,  namely,  relapsing  feT)er . 

This  is  no  new  form  of  disease.  It  was  described  more 
than  a  century  ago  by  Dr.  Rutty,  and  since  that  time  has 
prevailed  as  an  epidemic  disease  in  most  of  the  countries  in 
the  northern  part  of  Europe.  There  is  no  reliable  history 
of  its  occurrence  as  an  epidemic  in  this  country  until  about 
four  years  ago,  when  an  epidemic  prevailed  in  this  city. 
It  has  been  reported  that  in  the  year  1844  a  vessel  landed, 
in  Philadelphia,  passengers  ill  of  relapsing  fever.  At  one 
time,  while  typhus  fever  was  prevailing  in  Buffalo,  some 
twelve  or  fourteen  cases  of  relapsing  fever  were  reported, 
but  it  is  altogether  probable  that  they  were  cases  of  irregu- 
lar typhus  fever,  for  when  relapsing  fever  has  been  intro- 
duced into  a  locality  it  is  not  limited  to  one  or  two  dozen 
cases. 

Morbid  Anatomy. — In  this  disease  there  are  no  patho- 
logical lesions  of  so  uniform  occurrence  as  to  indicate  its 
special  anatomical  character.  In  a  word,  there  are  no  char- 
acteristic lesions.  There  are  changes  present  in  some  of  the 
organs  which  very  closely  resemble  those  that  are  met  with 
in  typhus. 

Spleen.— in.  the  majority  of  autopsies,  if  death  has  oc- 


MoKlill)    ANATOMY.  257 

currrd  in  tin'  active  jn'iiod  of  the  disease,  tlie  s})1<m'u  will  he 
found  consideiahly  incieasfd  in  size,  the  c'ai)sul(^  thickened, 
smootli,  tense,  and  sliirhtly  clomh'd,  the  trabt.'cuhe  of  the 
oraan  increased  in  size,  and  the  Mali)ighian  tnfts  more 
l)roniinent  tlian  normal.  In  some  cases  the  sj)lecn  will 
be  found  enhiriJiied,  soft,  and  tlahby.  There  is  no  uniform 
cliano:''  in  its  substance,  altliou,u;h  it  is  always  increased  in 
size  durinix  the  active  ])eriod  of  (lie  disease.  After  this 
])ei'i()d  lias  passed  it  will  be  found  diminislied  in  size,  and 
its  surface  will  present  a  shrivelled  ai)pearance,  with  the 
corpuscles  rolled  into  folds.  In  many  cases  a  number  of 
rounded  or  irregulai-  miliary  niasses,  of  a  dull  yellow  color, 
will  be  found. 

Lirir. — During  th<^  active  period  of  tlie  fever  this  organ 
will  also  be  found  enlarged,  and  enlargement  of  the  liver 
is  more  likeh'  than  enlargement  of  the  spleen  to  remain 
after  this  period  has  ])assed.  The  structural  cliange  which 
takes  place  in  the  liver  is  similar  to  that  found  in  the 
spleen.  The  urinc^  often  presents  a  cloudy  appearance. 
The  gall  l)ladder  is  generally  distended  with  dark  yellow 
bile. 

Kifhieys. — The  kidneys  will  be  found  increased  in  size. 
The  increase  is  due  to  congestion  of  the  cortical  substance, 
and  a  granular  infiltration  of  the  epithelium  of  the  urinifer- 
ous  tubules.  It  is  a  change  similar  to  that  noticed. in  other 
fevers. 

Intestines. — As  a  rule,  3-ou  will  find  enlargement  of  the 
glandular  follicles  of  the  iulestiues.  The  solitary  glands 
are  more  commonly  affected,  but  even  the  Peyerian  patches 
may  present  the  "shaven-beard"  appeamnce.  The  mes- 
entm'ic  gland  may  be  sliglitly  enlarged,  but  will  not  })resent 
any  change  indicative  of  an  infiammatory  process,  although 
there  is  some  congestion.  Its  appearance  is  similar  to  that 
noticed  in  typhus  and  typhoid  fevers. 

Mucous  Mcmfnanes. — In  the  majority  of  cases  you  will 
find  small  spots  of  blood-extravasation  upon  the  muitous 
surfacf^s,  especially  the  mucous  membranes  of  the  stomach 
and  intestines,  and  they  may  be  found  on  the  mucous  mem- 
branes of  the  broncliial  tubes.  These  spots  of  ecchj'iuosis 
17 


258  RELAPSING   FEVER. 

are  present  perhaps  as  constantly  as  any  pathological  lesion 
of  tlie  disease. 

Blood.— "^h.^  blood  coagulates  imperfectly,  as  in  typhus 
and  typhoid  fevers. 

Tlie  heart  presents  no  constant  changes.  In  some  cases 
fine  granular  infiltration  of  the  muscular  fibres  has  been 
observed.  This  same  granular  infiltration  is  also  sometimes 
seen  in  the  voluntary  muscles. 

All  the  other  changes  found  are  those  which  come  under 
the  head  of  complications. 

Etiology. — There  have  been  wide  differences  of  opinion 
and  much  discussion  in  regard  to  the  etiology  of  this  dis- 
ease. 

At  the  present  time  it  seems  to  be  the  unanimous  opinion 
of  those  who  have  had  the  best  opportunities  for  study, 
that  it  is  a  contagious  disease,  and  that  it  is  a  distinct  type 
of  fever.  Although  it  presents  many  phenomena  which 
ally  it  to  typhus,  and  many  other  phenomena  which  ally 
it  to  malarial  fever,  it  is  neither  typhus  nor  malarial,  but  is 
a  distinct  type  of  fever  having  a  distinct  poison.  From  ob- 
servations which  have  been  madeuj)on  the  blood  of  patients 
suffering  from  this  fever,  distinct  organisms  which  have  the 
power  of  developing  the  fever  are  thought  to  have  been 
found. 

Several  German  observers,  Cohnheim  and  others,  have 
given  drawings  of  these  organisms,  which  seem  to  be  little 
spiral  lines  that  are  constantly  in  motion,  and  these  observ- 
ers tell  us  that  they  are  distinctive  of  this  form  of  disease, 
and  are  always  present  during  its  active  period.  They  are 
absent  in  the  interval  between  the  primary  attack  and  the 
relapse,  but  are  to  be  seen  as  soon  as  the  relapse  occurs. 
With  reference  to  these  animal  organisms,  and  others  which 
are  claimed  to  be  the  cause  of  fevers  and  other  infectious 
diseases,  while  it  may  be  true  that  distinct  forms  are 
found  in  different  forms  of  fever,  I  question  very  much  if 
by  the  introduction  of  these  organisms  into  the  system  the 
fever  can  be  developed.  In  relapsing  fever,  more  than  in 
any  other,  have  these  organisms  been  seen  and  studied,  and 
yet  all  experimenters  have  failed  to  develop  the  fever  from 


MOIITUD    AX  ATOMY.  2.j9 

rlit'in.  Tliis  fact  gives  tliosc  who  do  not  Ix'licvo  tliat  livini; 
organisms  are  the  cause  of  infeclious  diseases  a  very  strong 
argument ;  yet,  on  the  other  liand,  does  nothing  for  tliose 
who  liold  tile  chemical  theory'  of  disease. 

It  seems  of  service  to  those  wlio  believe  that  every  disease 
has  its  own  specific  virus,  which,  as  yet,  we  have  not  been 
able  to  distinguish  either  l\y  its  microsco])ical  outline  or 
by  chemical  analysis,  but  which  is  believed  to  be  a  subtle 
agent,  similar  in  some  respects  to  the  venom  of  animals, 
aiul  which  acts  upon  the  blood  in  such  a  manner  as  to  cause 
the  development  of  the  living  organism;  this  organism  can 
be  seen  under  the  microscope. 

Clinical  experience  has  settled  the  question,  Is  relapsing 
fever  a  contagious  disease,  and  can  it  be  propagated  by 
personal  contagion?  Some  have  maintained  that  it  may  be 
conveyed  in  the  atmosphere,  in  water,  and  in  clothing. 
Some  of  the  clinical  facts  placed  on  record  a  few  years  ago, 
while  the  disease  prevailed  in  Germany,  go  to  prove  that 
the  fever  can  be  conveyed  from  the  sick  to  the  healthy  by 
means  of  water;  but  in  Ireland,  where  the  fever  seems  to  be 
indigenous,  there  is  no  such  evidence  on  record.  Usually 
it  has  prevailed  in  Ir.'laiid  when  there  has  been  a  scarcity  of 
food,  and  on  this  account  it  has  been  n-iiva^'([fnminf\frrer. 

However,  the  disease  is  not  necessarily  accompanied  by 
starvation,  for  it  is  developed  among  those  who  are  well  fed 
as  well  as  among  those  who  are  badly  nourished.  As  in 
tj'phus  fever,  there  is  a  connection  between  the  development 
of  an  epidemic  of  this  fever  and  imperfect  ventilation  and 
bad  h.ygiene. 

I  had  never  seen  a  case  of  rclajjsing  fever  until  about  four 
years  ago,  when  the  epidemic  prevailed  in  New  York.  At  that 
time  patients  were  brought  into  my  wards  in  Bellevue  Hos- 
pital with  a  fever  differing  from  typhus  fever  by  th(!  absence 
of  an  eruption,  from  intermittent  in  the  order  of  its  develop- 
ment, and  not  closely  resembling  remittent  fever.  It  sei-med 
to  me  an  irregular  form  of  nuilarial  fever,  differing  from  any 
form  with  which  I  was  acquainted,  as  at  that  time  I  was 
practically  unacquainted  with  the  phenomena  of  relapsing 
fever. 


260  -RELAPSING   FEVER. 

Eight  rasos  wore  brought  in.  From  these  my  house 
physician  contracted  the  fever,  and  during  his  illness  I 
reached  the  diagnosis  of  relapsing  fever.  Subsequently  we 
had  large  numbers  of  relapsing  fever  patients,  and  a  hos- 
pital was  established  for  their  reception  on  Hart's  Island. 

In  every  case  that  occurred  at  that  time,  where  the  origin 
of  the  fever  could  be  traced,  it  was  found  that  there  had  been 
direct  exposure,  and  it  was  established  beyond  doubt  that 
the  first  cases  were  brought  from  Ireland.  The  contagious 
character  of  the  affection  was  also  established  by  the  fact  that 
all  the  nurses  and  all  the  pliysicians  who  were  in  immediate 
attendance  upon  the  sick  contracted  the  fever.  If  a  patient 
was  placed  in  a  bed  before  it  had  been  cleaned,  previously 
occupied  by  a  person  sick  with  relapsing  fever,  he  was 
almost  certain  to  contract  the  disease.  At  the  time  of  this 
epidemic  we  found  no  evidence  that  the  fever  was  conveyed 
by  clothing,  although  some  British  writers  have  claimed 
that  it  can  be  done.  When  our  patients  were  admitted  into 
the  hospital,  their  clothing,  as  it  was  removed,  was  simply 
washed,  not  disinfected  in  any  special  manner,  then  packed 
away,  and  not  a  single  person  who  was  thus  brought  in  im- 
mediate contact  with  the  clothing  contracted  the  disease. 
The  period  of  incubation  ranges  between  five  and  seven 
days. 

Symptoms.— The  symptoms  which  usher  in  relapsing 
fever  are  usually  well  marked.  It  is  sudden  in  its  advent. 
This  is  marked  by  a  severe  rigor  or  by  a  distinct  chill.  Ac- 
companying the  chill  there  is  a  frontal  headache,  pain  in 
the  limbs,  more  or  less  pain  in  the  back,  nausea,  and  not 
infrequently  vomiting.  A  rapid  rise  in  temperature  follows 
the  chill,  and  with  its  appearance  the  headache  increases,  as 
does  also  the  pain  in  the  limbs,  especially  about  the  joints. 
There  is  vomiting,  at  first  only  of  the  simple  contents  of  the 
stomach,  afterwards  of  yellowish  material.  This  may  be 
followed  by  the  ejection  of  a  dark-colored  material,  which 
ver}^  closely  resembles  the  black  vomit  of  yellow  fever. 

In  this  disease,  the  rise  in  temperature  is  always  rapid, 
and  usually  marks  its  highest  point  within  the  first  twenty 
four  hours  ;  during  this  time  it  may  rise  from  98^°  F.  to 


SYMPTOMS.  261 

104°  F.,  or  oven  as  high  as  109°  P.  From  this  tiiiir,  for  two 
or  three  days,  there  is  usually  very  little  variation.  With 
the  o('eurrenc(»  of  the  ehlU  and  fever  there  is  also  a  ra])i(l 
increase  in  tlif  fii'tpii'iicy  of  tli<'  ])ulsi'.  In  no  disease  does 
the  pulse  so  quick!}'  beconu*  rapid  as  in  rela])sing  fever.  It 
is  not  unconiinon  for  it  to  n-acli  140.  l.")0,  or  even  lOo  beats 
]U'V  minuti' within  ili''  tirst  twenty-four  hours.  It  is  usually 
small  and  compressil)le. 

There  is  nothing  peculiar  about  the  countenance  of  the 
patient,  but  it  presents  the  ordinary  appearance  noticed  in 
an  active  febrile  excitement. 

As  the  disease  progresses  the  patient  becomes  more  and 
more  prostrated  ;  by  tlie  second  day  he  may  be  unable  to 
turn  in  bed.  The  arthritic  ])ains  increase  in  severity,  and 
often  become  the  most  distressing  symptoms  of  the  fever. 
As  early  as  the  second  day,  patients  begin  to  complain  of  a 
feeling  of  weight  and  uneasiness  in  the  upper  part  of  the 
abdomen,  more  severe  in  the  left  than  in  the  right  hypo- 
chondrium.  Usually  there  is  considerable  enlargement  and 
tenderness  of  the  liver.  Tlie  spleen  also  becomes  rapidly 
enlarged,  and  its  enlargement  is  attended  with  quite  severe 
pain  and  tenderness.  The  muscles  of  the  body  are,  how 
ever,  the  seat  of  the  most  severe  pain,  which  is  increased  by 
movement  and  by  pressure ;  the  pain  is  piercing  and  lancinat- 
ing in  character.  On  account  of  this  pain,  the  patient  usnally 
lies  perfectly  quiet ;  he  is  not  restless,  but  sleepless.  Deli- 
rinm  is  not  an  unfrequent  s3'mptom,  and  is  sometimes  very 
active,  yet  in  the  majority  of  nioderatel}'  severe  cases  the 
mind  remains  undisturbed.  There  may  also  be  present 
irregularities  of  thi?  pupils,  photophobia,  and  otlier  symp- 
toms wliich  might  lead  you  to  the  diagnosis  of  meningitis 
wer(,»  it  not  for  the  character  of  the  pulse. 

As  the  disease  progresses,  in  a  certain  ])roportion  of  cases 
jaundice  is  developed  ;  this  is  usually  acc()m])anied  by  vomit- 
ing and  severe  diarrhoea,  and  these  symptoms  seem  to  ally 
the  disease  to  some  forms  of  malarial  fever. 

The  great  prostration  and  iai)id  rise  in  tenii)eratnie  ally 
it  tf)  typhus  fevei-.  bnt  the  li-e  is  more  rapid  and  reaches  a 
higher  point  within  the  lirst  twenty-four  hours  tliaii  it  does 


262  EELAPSING  FEVER. 

in  typhus  fever.  There  is  sometimes  a  slight  rose-colored 
eru])tion  resembling  roseola,  but  liaving  none  of  the  char- 
acteristics of  typhus  eruption.  Tiie  patient  goes  on  from 
day  to  day  gradually  getting  worse,  the  fever  becomes  more 
and  more  intense  ;  loss  of  strength  and  emaciation  is  pro- 
gressive, and  the  muscular  pains  are  more  severe.  You 
may  have  been  watching  your  patient  with  the  greatest 
anxiet}^,  the  pulse  has  reached  160  per  minute,  the  tongue 
is  brown  and  dry,  extreme  nausea  and  vomiting  are  present, 
and  the  severity  of  the  symptoms  indicate  that  death  may 
speedily  occur,  when,  on  the  seventh  or  eighth  day  of  the 
fever,  suddenly  a  remission  occurs,  attended  by  a  profuse 
perspiration.  With  the  occurrence  of  the  profuse  sweating 
the  temperature  falls  ;  in  a  few  hours  it  may  fall  five,  six,  or 
even  seven  degrees  ;  the  pulse  becomes  less  frequent ;  the 
resi^irations,  which  have  been  hurried  and  difficult,  become 
regular ;  the  pains  in  the  head  and  limbs  pass  awa}'^,  the 
thirst  disappears,  the  tongue  becomes  moist ;  the  engorge- 
ment of  the  liver  and  spleen  rapidly  diminishes,  as  is  shown 
by  the  rapid  diminution  in  the  size  of  these  organs,  which 
is  readily  determined  by  percussion. 

Within  twelve  hours  from  the  commencement  of  the  re- 
mission, the  temperature  may  fall  to  less  than  100°  F.,  per- 
haps below  the  normal  standard,  and  the  pulse  may  fall  to 
80  or  90  beats  per  minute. 

Sometimes,  instead  of  a  profuse  perspiration  taking 
place  at  the  commencement  of  the  remission,  a  profuse 
hemorrhage  from  the  nose,  the  bowels,  or  uterus  may 
occur. 

As  soon  as  the  remission  occurs  the  patient  feels  perfectly 
well,  except  a  sense  of  weakness.  He  gets  out  of  bed,  and, 
if  he  is  in  a  hospital,  perhaps  insists  upon  his  discharge ; 
his  appetite  begins  to  return,  and  he  appears  to  be  rapidly 
convalescing. 

His  apparent  convalescence  is  of  short  duration  ;  some- 
times in  three  or  four  days,  usually  at  the  end  of  a  week, 
certainly  by  the  twelfth  or  fourteenth  day  of  the  disease, 
all  the  phenomena  of  the  primary  fever  are  suddenly  de- 
veloped, or  what  is  termed  the  relapse  occurs.     Sometimes 


svMi'roM>.  203 

the  relapse  occurs  in  tlie  morning,  sometiiiu^s  in  the  iiflci- 
noon.  hut  more  finiucntly  it  conies  on  at  night. 

Till'  ivlaj'si"  iiiny  be  ushered  in  by  a  chill,  oi-  it  may  occur 
without  a  chill.  The  pulse  may  begin  to  increase  in  ra],)i(lity 
and  in  (u.-lve  hoins  n-acli  140  ])er  minute.  With  the  rajjid 
pulse,  the  temperature  rapidlj-  rises  to  100°  F.  or  170°  F. 
and  even  as  high  as  180°  F.  Usually  tin'  fever  which  at- 
tt'iids  the  relapse  is  more  intense  than  the  primary  fever, 
the  liver  and  si)leen  become  as  enlarged  as  during  the  pri- 
mary I'evel'. 

It  is  claimed  by  some  observers  that  the  ])arasites  which 
are  said  to  be  present  in  the  blood  during  the  primary  fever, 
disappear  during  the  remission,  but  reappear  in  greater 
numbers  during  the  relapse.  The  relapse  usually  lasts 
three  or  four  days.  In  a  few  cases  I  have  seen  it  last  six 
or  seven  days,  and  in  some  it  does  not  continue  more  than 
forty-eight  hours.  After  it  has  continued  a  certain  period, 
a  second  remission  is  developed  ;  this,  like  the  lirst  remission, 
comes  on  suddenly,  is  accompanied  b}"  a  profuse  perspira- 
tion, and  in  twenty -four  hours  from  its  commencement  the 
pulse  and  temperature  have  reached  their  normal  standard. 
From  this  period,  the  patient  usually  goes  on  to  complete 
recovery. 

As  many  as  three  or  four  lelajjses  may  occur,  but  ordi- 
narily the  convalescence  becomes  complete  after  the  second 
remission. 

Convalescence  from  rela})siiig  fever  is  usually  rapid,  but 
the  patient  for  a  long  time  remains  in  a  weak  condition, 
suffering  more  or  less  from  ai'thritic  and  muscular  pains. 
The  apjjetite  returns  slowl}-.  An  anjemic  murmur,  which  is 
often  very  distinct  during  the  active  period  of  the  fever, 
is  heard  for  two  or  tliree  weeks  after  tlie  commencement  of 
convalescence.  Q^^dema  of  the  feet,  due  to  general  anaemia, 
is  often  quite  marked  duiiiig  convalescence. 

The  period  of  convalescence  is  usually  as  long  as  both 
the  period  of  fever  and  remission  ;  not  unfrequenlly  six  or 
eight  weeks  elapse  before  relapsing  fever  patients  are  able 
10  resume  their  accustouK^d  avocations. 

At  the  commencement  of  convalescence,  the  decrease  in 


264  RELAPSING   FEVER. 

the  size  of  tlie  spleen  is  rapid,  but  frequently  it  is  a  long 
time  before  the  organ  reaches  its  normal  size. 

Complications. — Few  complications  have  been  noticed 
during  the  course  of  relapsing  fever.  In  some  epidemics 
pneumonia  has  occurred  quite  frequently;  at  other  times  it 
has  been  exceedingly  rare.  When  it  does  occur,  it  is  often 
double. 

Sudden  collapse  may  occur  as  a  complication  of  relapsing 
fever,  either  during  the  primary  fever  or  during  the  relapse. 
Tlie  pulse  suddenly  becomes  small,  irregular,  or  inter- 
mittent, sometimes  imperceptible.  The  cardiac  impulse  is 
feeble,  the  heart  sounds  are  lost,  and  the  patient  rapidly 
passes  into  a  condition  of  collapse,  and  dies.  The  collapse 
may  come  on  suddenly  in  cases  previously  mild. 

Fost-fehrile  opMlialmla  is  another  very  remarkable  com- 
plication or  sequela  of  this  fever.  It  has  been  observed  in 
most  epidemics.  It  presents  two  distinct  stages,  the  amau- 
rotic and  the  inflammatory.  During  the  flrst  stage  the 
patient  complains  of  impaired  vision,  with  motes  and  lumi- 
nous circles  floating  before  the  eyes.  The  inflammatory 
stage  is  characterized  b}^  intense  circumorbital  pains  and 
lacrymation,  without  injected  conjunctivae  or  marked  con- 
stitutional disturbance.  Recovery  is  tedious,  and,  unless 
the  case  is  carefully  treated,  may  end  in  complete  loss  of 
sight.  Both  eyes  are  rarely  attacked  ;  the  right  eye  is 
most  frequently  affected. 

Dlarrhwa  and  dysentery  are  common  complications,  and 
in  some  epidemics  they  are  the  chief  cause  of  death.  They 
are  most  likely  to  come  on  during  the  relapse.  In  our 
epidemics  the  most  frequent  complication  is  hemorrhage 
from  the  mucous  surfaces,  especially  from  the  stomach  and 
intestines.  In  two  cases  that  came  under  my  observation 
hemorrhagic  pachymeningitis  was  the  cause  of  death.  In 
very  rare  instances,  abscess  of  the  spleen,  accompanied  by 
py?emic  symptoms,  have  occurred  during  the  relapse  and 
convalescence. 

Pregnant  females,  no  matter  at  what  stage  of  pregnancy, 
usually  abort  during  an  attack  of  relapsing  fever. 
Differential  Diagnosis. — The  diagnosis   of  relapsing 


]m:o(;no>;is.  2G5 

fever  is  not  difficult  iC  ynu  have  tln^  mtire  history  of  the 
case;  but,  at  the  eoinincHccnit'iit  of  an  ('])id('iiiie,  during 
the  })rinKir\'  fever,  you  will  n<'ccssaiily  be  in  doubt  as  to 
your  (.liaunosis. 

The  diseases  with  wliicji  it  is  ])ossil)le  to  confound  rejajis- 
ing  fever  are  typiius,  tyjilioid.  n-iiiit  h-iit,  yt-llow.  and  <h'n- 
gue  fever,  sinall-]>ox  (before  the  eruption),  and  measles. 

It  differs  from  all  these  diseases  in  the  suddenness  of  its 
invasion,  in  the  short  duration  of  the  ])iiniar\'  fev.-r,  and  in 
its  termination  in  a  crisis,  and  in  the  alnn)st  uniform  occur- 
rence of  a  relapse  between  the  third  and  fifth  days. 

Then  the  muscular  and  arthritic  pains,  which  an?  such 
constant  attendants  of  relapsing  fever,  distinguish  it  from 
the  other  forms  of  fever. 

A  severe  form  of  relapsing  fever,  attended  by  jaundice, 
resembles  very  closely,  in  its  general  appearance,  yellow 
fever  ;  but  the  high  temperature  and  ra])id  pulse  which 
attend  the  development  of  the  former  readily  distinguish  it 
from  the  latter ;  besides,  when  the  relapse  comes  on,  there 
can  no  longer  be  any  question  as  regards  diagnosis,  for 
yellow  fever  is  a  disease  in  which  a  relapse  rarely  occurs. 

Small-pox  simulates  relapsing  fever  only  duiing  the 
period  of  invasion.  You  need  make  no  doubtful  diagnosis 
after  the  third  day,  when  the  red  spots  appear  along  the 
edges  of  the  hair. 

Prognosis. — The  prognosis  in  relapsing  fever  is  always 
good.  During  our  ei)idemic  about  three  per  cent,  of  all  the 
cases  treated  in  hospital  terminated  fatally.  This  is  a  lower 
rate  of  mortality  than  we  have  with  measles.  Usually  deaths 
from  relai)sing  fever  occur,  not  from  the  disease,  l)ut  from 
some  complication.  During  the  epidemic  in  this  cit}',  syn- 
cope during  rela})se  was  the  most  frequent  cause  of  death. 

Rela])sing  fever  patients  may  dii'  of  hemorrhage  from 
some  of  the  mucous  surfaces.  A  fatid  t'-iininaiion  nuiy 
occur  from  bronchitis,  ])nenmonia.  or  otliei-  judmonary 
comi)li<'ations.  During  one  Russian  epidemic  ])arenchyma- 
tous  hemorrhage  was  a  freipn-nt  cause  of  dt-atli. 

Diai'i'lid'a  and  dysentery  occuiring  during  convalescence 
sometimes  cause  a  fatal  ternnnati<m. 


2(j(3  EELAPSIXG   FEVER. 

Sudden  suppression  of  urine  dependent  upon  renal  con- 
gestion may  give  rise  to  acute  urcCinia,  and  thus  cause 
death. 

M}^  own  experience  leads  me  to  the  belief  that  the  great- 
est danger  in  this  disease  arises  from  sudden  sj'ncope.  I 
remember  one  very  marked  case,  tliat  of  a  young  physi- 
cian, who  seemed  to  be  doing  well  in  his  second  relapse, 
when  suddenly  he  passed  into  a  state  of  syncope  and  died. 
At  the  post-mortem  examination  no  condition  of  the  in- 
ternal organs  was  found  which  would  account  for  his 
death. 

Treatment. — Dr.  Reilly,  who  wrote  upon  this  disease 
more  than  a  century  ago,  stated  that  all  those  cases  of  re- 
lapsing fever  which  were  abandoned  to  wliey  and  the  good 
providence  of  God,  recovered.  The  experience  of  a  century 
has  furnished  no  accepted  plan  of  treatment.  The  profes- 
sion are  still  unsettled  as  to  the  best  course  to  be  adopted 
in  the  management  of  this  disease. 

When  this  fever  appeared  in  our  midst,  we  thought  we 
could  control  it  by  large  doses  of  quinine,  but  we  soon  found 
that  quinine  was  of  no  service  in  its  treatment.  Then 
aconite  and  veratrum  were  employed  in  full  doses  as  anti- 
pj^'etics,  but  after  a  time  these  were  abandoned  as  useless. 

Cold  baths  were  resorted  to,  as  also  was  sjDonging  of  the 
surface  in  order  to  reduce  the  temperature,  but  in  their  use 
wx  were  disapj)ointed.  The  temperature  was  reduced  wiiile 
the  cold  was  being  applied,  but  rose  again  very  soon  after 
the  patients  were  removed  from  the  baths,  and  there  was  no 
effort  made  to  diminish  the  severity  or  shorten  the  duration 
of  the  primary  fever,  or  prevent  the  occurrence  of  the  relapse. 
Opium  in  full  doses  was  then  tried,  but  with  equally  un- 
satisfactory results,  although  its  free  use  was  found  to  give 
more  comfort  to  the  patients  than  did  any  other  plan. 

In  some  cases  stimulants  were  administered  quite  freely, 
bnt  without  any  apparent  beneficial  results. 

The  conclusion  arrived  at  was,  that  relapsing  fever  pa- 
tients were  as  well  without  as  with  medication.  I  would 
insist  that  relapsing  fever  patients  should  be  kept  quiet 
in  bed  during  the  primary  fever,  and  should  not  be  allowed 


TKKATMENT.  207 

to  leave  llu'ii-  rooms  mil il  iIk^  pciiotl  oT  relapse  slmll  liave 
passed,  and  that  llu'  -i.atest  caiu  sliould  Ix-  exercised  to 
guard  auaiiisi  ilic  occinreiice  of  synco]je.  If  lliere  is  evi- 
dence of  li<';iii  failiMv,  di^n-ilalis  and  stiiiiiilaiits  sliould  bo 
adminisiereil  aeeordiug  to  judical  ions.  .Moie  than  tliis  I 
have  n()tliiu<j:  to  su«>-,<>;est.  My  exi)erieuce  leads  rue  to  place 
relapsing  fever  i)atients  under  the  best  hygienic  nianage- 
nient,  with  free  ventilation  and  a  mild  diet,  and  then  care- 
fully watch  lest  some  complication  should  occur. 


LECTURE  XXIII. 


EXANTHEMATOUS  FEVERS. 

Small-Pox.— MorMd  Anatomy.— Etiology.— Symx>foms. 

This  morning  I  shall  commence  tlie  history  of  the  exan- 
thematous  fevers.  They  are  three  in  number,  small-pox, 
scarlet  fever,  ^.ndi  measles,  or  variola,  scarlatina,  and  rube- 
ola. These  are  distinct  diseases,  more  markedly  so  than 
any  of  the  varieties  of  fever  which  have  been  engaging  our 
attention. 

Some  writers,  not  regarding  them  as  distinct  diseases, 
have  described  them  under  the  general  head  of  acute  exan- 
tliematous  diseases.  It  seems  to  me  that  they  should  be 
included  in  the  list  of  fevers  :  first,  because  they  are  infec- 
tious, and  depend  for  their  development  upon  distinct  poi- 
sons as  specific  in  their  nature  as  those  that  develop  typhus 
or  typhoid  fever  ;  second,  for  the  reason  that  active  febrile 
symptoms  attend  their  development  and  mark  their  pro- 
gress ;  tJiird,  because  they  run  a  definite  course,  one  marked 
by  regular  stages  of  development  and  decline,  and  with  rare 
exceptions  they  attack  the  same  person  but  once. 

I  shall  speak  first  of  sniall-pox  or  variola.  Since  the  day 
of  .Tenner's  wonderful  discovery,  small-pox  has  not  occu- 
])ied  the  attention  of  the  profession  as  it  did  previous  to 
that  time.  Prior  to  this  discovery,  small-pox  was  dreaded 
like  the  plague,  and  when  it  did  prevail,  cities,  and  often 
whole  countries,  were  depopulated  b}^  it.  With  the  discov- 
ery of  vaccination,  a  new  era  was  developed  in  its  history. 
During  the  present  century  epidemics  of  small-pox  have 


MoKIiil)    ANA'I'oMV.  !2''>0 

not  Ihm'u  ,ij.-iv:il]y  IVinvd.  Diiiiim'  lli."  ]k\<\  six  or  ('i<;-lit 
years,  lio\vi-v.'i\  I  his  dis.'Ms.-  lias  Ixm'ii  oii  iIk;  increase,  and 
the  death  ivc<)r<ls  in  this  ciiy  show  that  some  years  then} 
have  been  more  (h'aths  from  sinall-pox  than  fi'oin  eithei- of 
tlie  other  exantheinatons  fcv.-is.  Why  this  _ii;reaf  increase, 
is  a  question  worthy  of  careful  con>i(lei:uion.  It  cannot  be 
from  an\-  failure  in  t  he  ])rotective  ])ower  of  the  nn'aiis  which 
we  ])ossess  [ov  i)reventin,L!;  its  develoi)ment,  but  I'roni  llie 
im])erfecr  manner  in  wliicli  sucli  nn'ans  are  employed.  Vac- 
cination. ])ro])-'rly  ]ierforme(l.  is  a  jx-rfect  ])rotection  against 
its  develoi)menl.  The  tinth  of  this  statement  no  one  of  ex- 
tended exi)erien('e  Avill  (iuesti(jn,  altlioni;-li  vaccination,  as 
formerly  jiractised  in  tliis  city,  seemed  to  fail  to  protect  tlie 
masses  from  the  contagion  of  small-pox. 

I  shall  consider  this  part  of  its  history  more  fully  under 
the  head  of  vaccination. 

I  will  now  call  your  attention  to  the  anatomical  lesions 
of  small-])ox.  Besidi^s  those  which  occur  ui)()n  tlui  mucous 
mi'nibraut's  and  skin,  congestions  of  the  iiitci'iial  oi-gans 
may  be  regarded  as  the  most  piominent.  The  anatomical 
changes  which  occur  in  all  cas(^s  will  vary  in  degree,  if  not 
in  kind,  witli  the  type  of  the  variola. 

Tliree  distinct  types  of  this  disease  are  recognized,  to 
which  have  been  given  the  names  '■''variola  fliscrda^'"  "  ta- 
riola  coiijluens,'"  and  ^'-variola  liemorrJnKjlcay 

MonniD  xVnatomv. — You  will  rarely  make  a  ])ost-morteni 
examination  u])ou  one  who  has  died  of  small-])ox,  without 
linding  more  or  less  intense  congestion  cf  the  lungs,  the 
l)rain,  the  liver,  the  spleen,  and  the  kidneys. 

Peihaps  the  most  constant  lesions  affecting  the  viscera 
are  ])arenchymatous  degenerations;  sometimes  these  are 
sim})lv  granular  infiltrations,  at  otiwr  times  they  consist  of 
an  acute  fatty  degeneration,  resembling  that  ])i()duced  by 
phosphorous  poisoning  ;   this  is  really  a  fatty  infiltration. 

If  the  liver  and  kidneys  are  far  advanced  in  fatty  cliange, 
the  walls  of  the  heart  will  usually  be  found  yellow,  thd)by, 
and  brittle. 

In  the  iKMuorrhagic  form  of  small-pox,  besides  these 
changes  you  will  find  small  hemorrhages  in  nearly  all  the 


270  SMALL-POX. 

viscera,  with  ecch3niioses  of  tlie  serous  membranes  and  fluid 
blood  in  the  cavities.  Every  mucous  membrane  may  be  the 
seat  of  a  hemorrhage. 

The  characteristic  anatomical  lesion  of  small-pox  is  to 
be  found  upon  the  mucous  membranes  and  upon  the  skin. 
This  lesion  is  usually  spoken  of  as  the  eruption.  It  does 
not  differ  essentially  in  the  different  varieties  of  the  disease  ; 
the  modifications  which  are  met  with  are  due  rather  to  its 
duration  and  order  of  development  than  to  any  difference 
in  the  anatomical  changes. 

If  we  study  closely  these  surface  lesions,  we  will  find 
that  they  pass  through  regular  stages  of  development  and 
decline.  The  first  change  that  is  noticed  looking  toAvards 
the  development  of  this  lesion  is  congestion  of  the  papillae. 
In  some  cases  this  congestion  seems  to  occur  in  spots,  while 
in  other  cases  it  is  quite  uniform.  The  congestion  of  the 
papilbie  gives  rise  to  the  little  red  spots  upon  the  surface, 
which  are  the  first  to  mark  the  development  of  the  eruption. 
The  papillae,  which  are  the  seat  of  the  congestioii,  will  very 
soon  be  found  to  be  surrounded  with  cells,  which  are  larger 
than  those  seen  in  the  normal  tissue  of  the  part.  These 
cells  very  rapidly  undergo  granular  degeneration.  Most  of 
these  cells  have  escaped  from  the  blood-vessels  or  are 
changed  tissue-cells.  As  these  new  cells  accumulate,  they 
cause  the  epidermis  to  become  elevated,  and  as  the  result  of 
the  elevation  we  have  a  little  papule  formed  at  the  point  of 
redness.  The  papules  which  are  formed  at  the  red  point 
are  due  to  the  changes  in  the  surrounding  cells,  changes  in 
the  rete-Malpighii  and  in  the  capillaries,  and  also  to  a 
certain  extent  to  new-cell  infiltration. 

After  these  changes  have  taken  place,  you  will  notice  a 
serous  infiltration  upon  the  surface  of  the  papule,  or  per- 
haps into  its  substance.  This  serous  fluid  is  simply  the 
serum  of  the  blood  which  has  escaped  through  the  walls  of 
the  congested  capillaries,  and  formed  upon  the  top  of  the 
papule  a  little  elevation  which  is  recognized  as  a  vesicle. 

In  a  certain  proportion  of  cases,  you  will  find  that,  soon 
after  the  vesicle  begins  to  form,  its  centre  becomes  de- 
pressed.    This  depression  or  umhllicaUon^  as  it  is  usually 


:\fn];iMI)    AN'ATo>rV.  271 

callt',1,  has  been  accountfd  for  in  dilT.'Tvnr  ways  by  (liir.-niit 
obsorvers. 

Some  explain  it  by  saying  that  »ach  ])apule  and  subse- 
quent vesiide  liohls  iniprisou.'d  at  its  centre  eitlier  a  hair- 
folliele  or  the  duct  of  a  sw.at-<,dand,  and  tliat  Avlicn  this 
ei>idermidal  layer  of  the  papule  is  elevated  by  the  serous 
exudation  or  infiltration,  the  portion  immediately  about  the 
hair-follicle  or  the  sweat-duct  is  held  down,  and  a  depn^s- 
sion  is  produced  at  the  exact  point  where  the  hair-follicle 
or  duct  of  the  inland  maybe  situated.  Anotlier  exi)hination 
(which  I  regard  the  better  one)  of  the  umbilication  of  the 
vesicle  is,  that  the  serous  infiltration  takes  place  more 
rapidly  at  the  p<M-iphery  of  the  vesicle  than  at  its  centre ; 
consequently,  the  former  becomes  more  elevated  than  the 
latter. 

Umbilication  of  the  vesicle  is  by  no  means  of  constant 
occurrence,  as  can  be  readily  ascertained  by  close  examina- 
tion of  a  number  of  vesicles. 

We  have  considered  those  anatomical  (dianges  which  take 
place  in  the  papule  and  vesicle.  Now  anothei-  ])rocess  com- 
mences, pus-cells  or  wdiite  blood-globules  from  the  capilla- 
ries migrate  into  the  surrounding  tissues  and  into  the 
vesicles,  and  as  a  result  the  vesicles  change  in  color.  In 
other  words,  the  vesicles  become  changed  into  pustules. 
At  the  same  time  an  inflammatory  process,  more  or  less  ex- 
tensive, is  going  on  in  the  walls  of  the  pustule,  and  in  the 
surrounding  cellular  tissue,  which  t<M-minates  in  a  destruc- 
tion of  tissue  at  the  point  where  the  papillary  congestion 
first  occurred.  If  only  the  superficial  layer  of  the  skin  is 
involved,  the  infiltration  of  i>us-cells  into  the  vesicle  and  the 
formation  of  the  pustule  may  take  ])lace  without  extension 
of  the  inflammation  into  the  cellular  tissue  beneath,  and 
necrosis  or  death  of  the  jiart  will  not  follow  ;  but,  if  y<ui  have 
the  inflammation  extending  into  the  deeper  tissues,  a  slough 
will  be  ]U(>duced,  which  necessarily  will  be  followed  by  a 
cicatrix  and  i)itting. 

Remember  that  pitting  is  the  result  of  a  slough  that  has 
been  ])roduc<>d  by  an  extension  of  the  inflammatory  process 
into  the  deeper  tissues. 


272  SMALL-POX. 

Wlien  the  cellular  tissue  becomes  involved  in  inflamma- 
tion it  readily  undergoes  the  sloughing  process.  This  is 
the  reason  why  we  have  pus  so  readily  formed  and  in  such 
quantities,  when  in  any  pax't  of  the  body  an  apparently 
s]i<Tht  degree  of  inflamnuitory  action  invades  this  tissue.  I 
dwell  upon  this  point,  for  it  has  a  bearing  upon  the  treat- 
ment of  the  pustule,  for  which  a  long  list  of  remedies  has 
been  proposed  with  the  view  of  preventing  pitting.  Pre- 
vention of  pitting  will  depend  upon  the  extent  of  the  inflam- 
matory process;  if  it  involves  the  cellular  tissue,  pitting 
will  follow  in  spite  of  all  the  applications  that  may  be  made. 
You  may  prevent  pitting  if  you  can  find  any  means  of  arrest- 
ing the  inflammatory  process  before  it  involves  the  cellular 
tissue.  After  the  pustule  is  formed  the  inflammatory  pro- 
ducts begin  to  dry  down,  and  a  crust  is  formed  which  con- 
tracts in  the  central  portion,  and  the  same  umbilicated 
appearance  is  presented  that  is  seen  in  the  umbilicated 
vesicle.  After  a  time  these  crusts  are  separated  by  the  or- 
dinary changes  which  occur  in  the  subsidence  of  an  inflam- 
matory process,  and  recovery  is  complete,  except  that  there 
is  left  behind  a  cicatrix,  which  undergoes  the  same  changes 
as  does  a  cicatricial  tissue  formed  under  any  other  circum- 
stances. 

I  have  now  briefly  described  to  you  the  anatomical  lesions 
of  a  variola  pustule.  I  would  add  that  these  pustules  may 
be  formed  upon  any  of  the  mucous  membranes  of  the  body. 
They  are  also  frequently  formed  upon  the  mucous  membrane 
of  the  stomach,  intestines,  bronchial  tubes,  larynx,  and 
upon  the  conjunctiva?.  The  surface  of  the  body  is  the  place 
where  they  are  most  abundantly  developed.  The  anatomi- 
cal changes  which  take  place  in  the  skin  and  mucous 
surfaces  are  similar  to  those  which  attend  any  ordinary  in- 
flammatory process.  These  inflammatory  processes  are  set 
up  by  a  specific  small-pox  poison,  which  carries  with  it  a 
tendency  to  produce  destruction  of  tissue  at  the  point  wiiere 
the  inflammation  is  established.  In  the  milder  forms  of 
small- pox,  pitting  does  not  occur,  but  in  severe  forms  it  is 
ahvays  present  to  a  greater  or  less  degree. 

There  is  nothing  specific  or  essentially  different  in  the 


P/rroLnfiY.  273 

dcvt'lopnuMit  of  tlic  i)uslul('s  in  ]i<Mii(>n'li:>ii:ic  sji);ill-])()X 
rroiu  their  (It'vclojtmciit  in  the  ordinary  forms  of  the  disease  ; 
the  only  diUnviice  is.  that  tiieir  contents  are  bloody  instead 
of  serons  or  pnndent. 

In  tlie  liejnorrhagic  variety,  hirger  or  sniaUer  lieinorrlui- 
ges  take  place  into  the  cellular  tissues  ;  in  the  milder  foiTns 
they  tnke  place  only  in  the  layer  beneath  the  ])apilla' ; 
while  in  the  severer  forms  they  take  jjlace  beneath  all  the 
cutaneous  layers ;  even  the  subcutaneous  fat  may  be  infil- 
trated with  blood.  No  changes  in  the  walls  of  the  vessels 
have  as  yet  been  discovered  which  will  account  for  these 
hemorrhages.  These  extravasations  more  frequently  occur 
in  those  cases  in  wliich  (h-ath  takes  place  before  the  period 
of  ])Ustulation  is  reached. 

Etiology. — The  etiology  of  small-pox  is  a  subject  which 
at  different  times  has  engaged  the  attention  of  the  profes- 
sion. At  the  present  day  the  opinion  is  almost  universal 
that  the  disease  is  propagated  only  by  contagion  ;  that  is, 
that  it  is  a  disease  which  can  only  be  produced  by  its  own 
specific  poison,  and  is  communicable  only  to  persons  who 
are  not  protected  from  its  influence. 

There  has  been  considerable  question  as  to  where  the  vi- 
rus of  small-pox  is  located.  Some  claim  that  it  is  exclu- 
sively in  the  pustule,  and  that  it  is  not  possible  for  a  person 
suffering  from  small-pox  to  give  the  disease  to  an  unpro- 
tected individual  unless  some  of  the  virus  from  the  pustule 
is  brought  in  contart  with  a  cutaneous  or  mucous  surface. 

This  is  a  mistake.  That  small-pox  can  be  conveyed  by 
means  of  virus  taken  from  a  pustule  there  can  be  no  ques- 
tion ;  but  you  may  rul)  the  cutaneous  surface  of  an  unpro- 
tected person  with  pus  taken  fiom  a  small-]iox  ]>iistnlt\  and 
unless  there  is  an  abrasion  of  the  surface  the  ])oison  will 
not  enter  the  body  and  the  person  will  not  become  inocu- 
lated with  I  lie  disease  ;  but  if  you  ])lace  the  virus  in  contact 
with  a  mucous  membiane  of  an  un])rotected  p<M"son  he  will 
almost  certainl}-  contract  the  disease.  It  is  equally  certain 
that  the  disease  can  be  coiiiiimnicated  fiom  one  person  to 
another  by  means  of  the  lu-eath  and  exhalations  from  the 
skin.  There  is  no  evidence  that  the  disease  can  be  con- 
18 


274  SMALL-POX. 

veyed  by  the  discharges  from  the  bowels.  Perhaps  if  a 
pustule  should  be  developed  somewhere  along  the  line  of 
the  intestine  the  discharges  may  become  so  contaminated  as 
to  have  the  j^ower  of  communicating  the  disease. 

Small -pox  can  also  be  conveyed  from  one  individual  to 
another  through  the  atmosphere.  In  the  open  air  the  dis- 
tance of  contagion  is  about  two  and  one-half  feet.  In  a 
small  room  the  atmosphere  may  be  so  contaminated  that 
an  unprotected  person  will  contract  the  disease  upon  a 
single  entrance  into  the  room. 

The  disease  can  be  conveyed  in  clothing,  and  the  poison 
will  remain  for  a  long  time  in  clothing,  unless  it  has  been 
exposed  for  a  considerable  time  to  the  air.  In  other  words, 
there  is  no  doubt  but  that  it  is  a  portable  disease.  In  order 
that  the  disease  may  be  transferred  by  means  of  the  clothing 
or  merchandise,  it  is  necessary  that  the  clothing  or  mer- 
chandise contain  the  pus  or  crusts  from  the  small-pox 
pustules  ;  how  long  a  time  may  elapse  before  the  virus  loses 
its  vitality  is  not  known.  There  are  well -authenticated 
cases  in  which  it  has  retained  its  virulence  for  more  than  a 
year. 

No  period  of  life  is  exempt  from  the  contagion  of  small- 
pox ;  even  intra-uterine  life  is  in  danger  from  infection. 
Rarely  does  an  individual  have  a  second  attack.  I  remem- 
ber one  exception,  that  occurred  in  the  person  of  a  young 
Swedish  woman,  who  under  my  observation  passed  through 
three  well-developed  attacks  of  the  disease ;  the  last  attack 
was  the  most  severe. 

Concerning  the  exact  nature  of  the  small-pox  virus 
nothing  definite  is  known. 

Some  observers  claim  that  the  earliest  period  at  which 
one  suffering  from  this  disease  can  infect  the  unprotected  is 
the  period  of  suppuration.  Others  claim  that  the  infecting 
period  is  during  the  stage  of  desiccation.  There  are  well- 
authenticated  cases,  however,  which  prove  to  us  that  infec- 
tion may  take  place  during  any  stage  of  the  disease,  even 
during  the  period  of  incubation.  There  is  little  doubt  but 
that  the  suppurative  stage  is  the  most  infectious  period. 

There  are  differino;  views  as  to  the  manner  in  which  the 


SYMPTOMS.  276 

siiim11-])i»x  ])(>is(>n  i:;:iiiis  cut  raiici"  into  tin-  syslrin  ;  IIh-  most 
})r()b;il)lt'  of  tlu'sr  virws  is,  Ihat  it  is  priiicipMll}'  iibsorlx'd 
by  the  mucous  mt'ml)niiit'  of  tlir  ii'spiratory  truck  during 
res})iration,  and  it  is  also  jxohaltlf  that  exceediuf^ly  iine 
particles  detach  from  the  ])uslul('s  and  crusts,  which  are 
suspended  in  great  num])ers  in  tlie  air  surrounding  small- 
pox patients,  and  that  these  convey  the  contagion,  Tliere 
are  no  facts  to  sustain  the  recent  views  as  to  tlie  parasitic 
nature  of  this  contagion. 

The  length  of  time  wdiich  elapses  after  exposure  to,  and 
n'ception  of,  the  variola  contagion  before  the  disease  is  de- 
veloped varies  from  ten  to  thirteen  days.  This  is  called  the 
period  of  inouhatioti,  during  which  the  recipient  of  the 
poison  usually  presents  no  abnormal  symj^tonis.  If  the 
poison  is  introduced  into  the  system  through  inoculation, 
only  fortj'-eight  hours  elapse  before  the  characteristic  phe- 
nomena of  the  variola  are  manifested.  It  is  not  known 
what  change  takes  place  in  the  body  of  the  infected  person 
during  this  period  of  incubation.  Usually,  twelve  days 
after  exposure,  the  person  who  has  contracted  small-pox 
begins  to  feel  chilly  ;  this  feeling  of  chilliness  increases  until 
he  has  a  distinct  chill.  This  has  been  termed  the  initial 
stage,  or  the  stage  of  initiatory  fever. 

Symptoms. — TIk,'  transition  from  the  stage  of  incubation 
to  that  of  initiatory  fever  is  sometimes  abrupt  and  some- 
times gradual  ;  usually  it  occupies  two  days  and  is  fol- 
lowed by  the  eru]>tion.  In  this  stage  there  is  greater  vari- 
ation in  the  intensity  than  in  the  duration  of  the  symjitoms. 
The  intensity  of  the  symptoms  bears  no  relation  to  the 
severity  of  the  attack.  Not  unfreiiurntly,  the  most  violent 
S3'mi)toms  in  the  initial  stage  are  followed  by  a  mild  attack 
of  variola  ;  wliilr  mild  symptoms  in  tln'  iintial  stage  are  fol- 
lowed l)y  the  gravest  form  of  small- jiov.  With  the  chill, 
which  maj'  be  more  or  less  severe,  there  is  s«'vere  pain  in 
the  head  and  back,  especially  in  the  middle  of  the  back; 
with  this  ])ain  there  will  be  a  ra])id  rise  in  tem])eiature. 
During  the  first  day  the  temi)erature  may  rise  to  104"  F., 
during  the  second  day  to  105°  F.,and  by  the  third  day  it 
mav  reach    loG°  F.  or   107    F.  ;  in   some  cases  it  has  been 


276  SMALL-POX. 

said  to  liave  reached  109°  F.  With  this  rise  in  temperature 
there  will  be  an  acceleration  of  pulse  ;  it  may  reach  100  or 
120  beats  per  minute.  In  the  strong  and  robust  person,  the 
pulse  will  be  I'uU  and  not  easily  compressed.  In  females, 
and  in  the  weak  and  feeble,  the  pulse  has  less  volume,  but 
usually  is  more  frequent ;  it  may  reach  140  beats  per 
minute. 

At  the  very  onset  of  the  disease,  the  pulse  become  mark- 
edly increased  in  frequency,  and  the  temperature  becomes 
very  much  elevated. 

At  this  period,  usually,  there  is  more  or  less  nausea  and 
vomiting,  and  there  will  be  soreness  of  the  throat.  This 
soreness  of  the  throat  may  have  preceded  the  chill  by 
twenty -four  hours,  but  now  in  many  cases  it  will  be  quite 
severe,  and  the  patient  will  comi^lain  of  more  or  less  difficulty 
in  swallowing,  and  of  pain  in  the  pharynx.  The  extent  of 
the  trouble  in  the  throat  will  depend  upon  the  severity  of 
the  attack. 

In  the  severer  forms  of  the  disease,  by  the  tliird  or  even 
before  the  end  of  the  second  day,  there  may  be  delirium. 
In  all  cases,  the  face  will  be  flushed,  the  conjunctivse  con- 
gested, and  there  will  be  throbbing  of  the  carotids.  "With 
these  sj^mptoms,  there  will  be  great  restlessness,  and  an 
anxious  expression  of  countenance,  with  somnolence.  The 
respirations  will  be  short,  frequent,  and  labored.  Many 
suffer  from  extreme  vertigo,  and  in  children  convulsions  are 
not  infrequent.  By  the  evening  of  the  second,  or  morning 
of  the  third  day,  usually  swelling  and  diffuse  redness  of  the 
tonsils  and  soft  palate  are  present ;  not  unfrequently  the 
swelling  and  redness  of  the  mucous  membranes  extends  into 
the  larynx,  causing  hoarseness  and  huskiness  of  the  voice 
and  a  stridulous  cough. 

Some  writers  describe  an  initial  erythematous  rash  which 
precedes  tlie  eruptive  stage  of  small-pox.  This  rash  is  so 
rarely  met  with  in  this  country  that  it  seems  to  me  to  be  an 
accidental  occurrence  rather  than  a  symptom  of  the  initial 
stage  of  the  disease. 

During  the  fever  of  invasion  patients  are  languid  and 
weak  in  projDortion   to   the   severity   of   the  fever.     Fre- 


SYMPTOMS,  277 

qiKMitly,  williiii  twenty-four  hours.  nft'T  the  usln-iiuij:  in 
rhill  the  stiongesL  luid  must  vi^'orous  will  he  unable  Lo  ^et 
out  of  hed. 

Thei-e  is  iihva3'S  loss  of  appetite  ;  nausea  and  v()niitin<^  are 
fiequentl}' i)resent.  If  vomiting' occurs  it  is  present  at  tlie 
very  beginning  of  tlie  initial  fever,  and  continues  with  great 
obstinacy  throughout  its  entire  course.  in  the  henioiilin- 
gic  variety  the  matters  vomited  may  contain  blood. 

Stage  of  Empfioiis. — By  the  third  day  of  the  disease,  at 
least  after  the  initial  fever  has  continued  three  full  days, 
an  eruption  will  make  its  appearance  ii])on  the  face,  espe- 
cially along  the  edges  of  the  hair. 

I  will  describe  the  eruption  as  it  develops  in  a  moder- 
ately severe  case  of  discrete  variola.  It  first  ap})ears  in  the 
form  of  slightly  elevated  macuhe.  These  are  of  a  pale  red 
color,  varying  in  size  from  a  millet-seed  to  a  pin's  head,  or 
even  larger.  These  little  red  spots  look  veiy  much  like  flea- 
bites.  In  most  cases  the  forehead,  nose,  and  ui)per  lips  are 
covered  lirst.  If  you  closely  watch  them  you  will  find  that 
they  gradually  increase  in  size  ;  the  increase  is  attended  b}' 
a  sensation  of  itching  and  burning  of  the  surfa(;e.  Usually, 
about  twelve  hours  after  their  appearance  upon  the  face, 
similar  small  red  points  appear  upon  the  body  and  extrem- 
ities; first  on  the  body,  then  on  the  legs  and  arms,  and 
lastly  on  the  hands  and  feet.  They  are  always  less  abun- 
dant on  the  body  and  extremities  than  on  the  face.  On  the 
second  day  of  the  erui)tion  these  sjjots  assume  a  daiker 
red  coloi-,  become  elevated  and  distinctly  papular.  On  lln' 
third  da}'  tliey  becojue  more  conical  in  sliapi',  and  at  theii- 
ai>ex  a  vesicle  is  formed,  which  gradually  enlarges  until  the 
fourth  or  fifth  day,  when  they  reach  the  size  of  a  small  pea, 
and  ai'e  s])herical  in  shape. 

In  a  majority  of  instances,  as  tiny  iiilaige,  a  dej)ressi()n  is 
formed,  which  gives  to  them  an  unibilicated  ap})earance. 
At  the  centre  of  the  depression  the  ojx'uing  of  a  hair- 
follicle  or  sweat-gland  will  often  be  found.  The  appear- 
ance of  eruption  is  attended  ]»y  a  subsidence  of  the  febrile 
sym])toin<,  tlie  ])atieiir  no  longer  com])laiii^  i>f  pains  in  the 
head  and  back,  the  temperature  falls  two  or  three  degrees, 


278  SMALL-POX. 

and   the  pulse  diminislies  fifteen  or  twenty  beats  in  fre- 
quency. 

Stage  of  Suppuration.  —  Ahout  tlie  sixth  day  of  the 
eruption  the  contents  of  the  vesicle,  from  the  admixture  of 
pus-corpuscles,  gradually  become  turbid,  and  by  the  eighth 
day  the  pustules  become  fully  formed,  and  the  disease  en- 
ters on  the  stage  of  suppuration.  The  integument  in  the 
immediate  vicinity  of  the  pustule  now  becomes  red  and 
tumefied,  each  pustule  being  surrounded  by  a  broad  red 
base,  and  where  they  are  thickly  set  they  become  conflu- 
ent. The  face  swells  to  a  shapeless  mass,  and  the  patient 
becomes  frightfully  deformed.  The  itching  now  becomes 
almost  unbearable,  and  causes  the  patient  to  scratch  him- 
self, thus  causing  ultimate  disfigurement.  During  this  pe- 
riod a  characteristic  sickly  odor  is  emitted. 

As  I  have  already  stated,  the  eruption  appears  on  the 
trunk  and  extremities  a  day  or  two  later  than  on  the  face, 
and  on  these  parts  it  passes  through  its  stages  two  or  three 
days  later  than  it  does  on  the  face  ;  consequently,  suppura- 
tion may  be  complete  on  the  face  while  it  is  still  taking 
place  on  the  extremities,  and  the  eruption  may  be  perfectly 
discrete  on  the  trunk,  while  it  is  confluent  on  the  face. 

About  the  eighth  or  ninth  day  of  the  eruption  the  pus- 
tule is  fully  formed  ;  the  stage  of  suppuration  is  complete. 
Then  commence  the  retrograde  changes.  The  pustule  either 
ruptures,  discharges  its  contents,  dries  up  and  forms  a  yel- 
lowish crust,  or  it  shrivels  and  dries  up  witho-ut  rupturing. 

This  is  called  the  period  of  desiccation. 

Stage  of  Desiccation. — Desiccation  commences  in  those 
parts  in  which  the  eruption  first  appeared.  As  the  drjdng 
down  of  the  pustules  takes  place,  the  redness  and  tenderness 
of  the  skin  lessens,  and  the  countenance  begins  to  assume  a 
more  natural  appearance.  At  first  the  crust  adheres  quite 
firmly  to  the  surface,  but  between  the  eleventh  and  four- 
teenth day  of  the  eruption  it  is  separated  from  the  surface 
and  falls,  leaving  a  stain  of  a  reddish-brown  color,  with  ele- 
vated edges  and  depressed  centre,  which  remains  visible  for 
five  or  six  weeks.  These  spots  gradually  become  lighter  in 
color,   until  finally,   if  there  has  been  destruction  of  the 


SYMPTOMS.  279 

cutis,  a  ])it  will  be  fornu'd  of  iri-t-attT  <>r  less  depth,  of  a 
wliitt'  color,  .Lciviii-i;  to  tlif  face  a  "  *  ]iock-mark<'d"  a|)j)ear- 
aiu't',  which  will  remain  duriiiii;  the  life  of  the  iiulividual. 

1  liav.'  already  stated  to  you  iliat  the  febrile  syni])toms 
ii:radually  increase  in  severity  until  the  third  day  of  tlu;  dis- 
ease, when  the  eruption  a})pears  and  the  fever  sul)sides. 
Then  the  vesicles  form,  the  formation  (jf  which  is  attended 
by  only  moderate  fever.  On  the  eighth  day  the  ])ustules 
are  fully  formed,  and  the  suppurative,  or,  as  it  is  called,  the 
second  a  nj  fever  comes  on.  This  secondary  fever  often 
commences  with  a  distinct  chill,  the  pulse  becomes  frequent, 
the  temi)erature  rapidly  rises,  perhaps  reaches  a  higher  ele- 
vation than  it  did  during  the  initial  fever,  sometimes  rising 
as  high  as  108°  F.  or  109°  F.  ;  it  reaches  its  nuiximum  when 
su]ipuration  is  at  its  height.  As  desiccation  commences, 
the  temperature  begins  to  fall,  and  by  the  time  the  crusts  are 
fully  formed  the  temperature  reaches  very  nearly  a  normal 
standard.  If  the  temperature  rises  again,  its  rise  is  due  to 
some  complication,  such  as  erysipelas  or  some  phlegmonous 
process.  With  the  fall  of  the  crusts,  the  patient's  appetite 
returns  and  he  is  able  to  sleep  ;  convalescence  is  now  fully 
established. 


LECTURE    XXIV. 


SMALL-POX 


Symptoms  {continued).  —  Differential  Diagnosis.  —  Prog- 
nosis. 

I  HAVE  already  given  you  tlie  liistory  of  the  symptoms  of 
an  ordinary  case  of  discrete  small-pox.  This  may  be  regarded 
as  a  prototype  of  all  varieties.  This  morning  I  shall  call 
your  attention  to  the  points  of  difference  between  the  other 
varieties  of  small-pox  and  that  variety  whose  history  we 
have  been  considering.  The  dividing  lines  between  these 
different  varieties  are  not  sharply  defined;  one  varietj^  grad- 
ually passes  into  another  variety. 

It  is  unnecessary  for  me  to  consider  all  the  forms  into 
which  this  disease  has  been  divided  by  medical  writers ; 
frequently  the  basis  of  the  division  is  merely  arbitrary.  We 
will  therefore  confine  our  attention  to  the  more  common 
and  well-recognized  varieties. 

Confluent  Small-pox,  or  Variola  Confluens. — This  is  a 
much  more  severe  form  of  the  disease  than  variola  discreta. 
It  develops  far  more  rapidly  and  is  much  more  fatal  in  its 
results. 

The  fever  of  invasion  is  usually  much  more  severe,  and  of 
shorter  duration,  frequently  not  lasting  more  than  forty- 
eight  hours.  The  eruption  spreads  rapidly  over  the  entire 
body,  often  appearing  simultaneously  on  the  face  and  the 
other  portions  of  the  body.  The  red  dots  which  mark  the 
first  appearance  of  the  eruption  are  very  numerous,  especially 
on  the  face  and  hands  ;  on  the  first  day  of  their  appearance 


SYMrT(>Ms.  2R1 

they  are  almost  ronflucnl.  On  tli<'  s(>r(m(l  day  the  skin  is 
int(MiS('ly  red  inid  swolh'ii,  and  so  tliit.'kly  studded  witli 
lai;uv  llal  \i'>iclcs  thai  they  r:i])idly  unit.(^,  sii])iiiirai  ion 
spcH'dih'  follows,  and  llali'-nrd.  yllowislicoloi-cd  conliucnL 
])at("luvs  aiv  roinicd  u]h)Ii  a  dark,  irddrufd,  swollen  skin. 
Giadiially  tliese  ])atclies  run  togetlier  over  a  still  larger  sur- 
face, and  tile  epidernus  is  elevated  in  llie  foiin  of  lar.i^e,  Hat 
bulhe,  which  are  filled  with  a  sero-i)urulent  llnid.  In  this 
way  the  entire  skin  of  the  face  is  covered  by  an  immense 
bulla,  and  I  he  patient  is  as  unrecognizable  as  though  he  wore 
a  mask.  While  the  eruption  may  be  completely  conlluent 
on  the  face  and  hands,  on  other  jjarts  of  the  body  it  remains 
distinct,  and  never  becomes  conlluent  except  over  limited 
spaces. 

The  period  of  desiccation  is  slowly  reached.  Large  con- 
centric crusts  are  formed  over  the  confluent  patches  ;  these 
adhere  firmly  to  the  skin,  while  b(^neatli  them  suppuration  of 
the  papillary  layer  continues.  The  true  skin  is  more  or  less 
extensively  destroyed,  and  when  the  crusts  have  fallen,  there 
is  left  extensive  loss  of  substance  in  the  cutis,  giving  rise  to 
pits  and  ugly  scars,  which  have  a  tendency  to  contract,  often 
producing  permanent  and  unsightl}^  disfigurements.  In  tliis 
vai-iety  of  small-pox,  the  eruiition  is  often  confluent  upon 
the  mucous  mend)rane  of  the  mouth  and  throat ;  it  may  in- 
volve the  mucous  membrane  of  the  posterior  nares,  and  ex- 
tend into  the  larynx.  In  sonn?  cases  the  attending  ])haiyn- 
gitis  is  so  severe  as  to  lender  di'glutition  imi)ossil)le.  The 
pharyngeal  inflammation  is  submucous,  and  is  frequently 
accompanied  by  more  or  less  enlargement  of  the  parotid 
and  sublingual  glands.  When  this  condition  exists  there 
is  danger  of  the  sudden  development  of  a?dema  glottidis,  for 
the  occurrence  of  which  you  should  bt^  on  the  watch.  Du- 
ring the  year  that  I  had  charge  of  the  Snudl-pox  IIos])ital, 
there  were  three  cases  in  the  hospital  of  twlema  glottidis; 
one  case  ternnnated  fatally  before  I  reached  the  patient ; 
life  was  saved  in  the  other  two  cases  by  the  performance  of 
laryngotomy. 

In  confluent  small-])ox  the  severity  of  the  constitutional 
sym])toms  corresi)onds  to  the  severity  of  the  local  manifes- 


282  SMALL-POX. 

tations.  The  temperature  during  the  initial  fever  often 
readies  10G°  F.  or  107°  F.,  and  in  very  severe  types  of  the 
disease  it  may  rise  as  high  as  110°  F.  The  pulse  is  corre- 
spondingly frequent  and  feeble.  After  the  appearance  of  the 
eruption  the  temperature  falls  slowly  to  103°  F.  or  104°  F., 
where  it  remains  until  the  stage  of  suppuration  is  reached ; 
then  it  again  rises,  in  some  cases  even  higher  than  during 
the  period  of  invasion.  Violent  delirium  is  very  frequently 
present  during  the  fever  of  invasion,  as  well  as  during  the 
period  of  secondary  fever,  and  not  infrequently  patients 
pass,  quite  suddenly,  into  a  state  of  coma.  Uncontrollable 
vomiting  and  obstinate  diarrhoea  are  not  infrequent,  coming 
on  during  the  fever  of  invasion  and  continuing  throughout 
the  course  of  the  disease.  In  all  severe  cases  typhoid 
symptoms  manifest  themselves  soon  after  the  appearance  of 
the  eruption,  and  patients  often  lie  for  days  in  a  semi-con- 
scious state,  with  dry,  brown  tongue,  subsultus,  a  low 
muttering  delirium,  and  all  the  attendant  phenomena  of 
intense  nervous  depression.  In  all  severe  cases  albumen 
appears  temporarily  in  the  urine. 

Complications  occur  much  more  frequently  in  confluent 
than  in  discrete  small-pox.  Inflammations  of  the  serous 
membranes,  especially  pleurisy  and  pericarditis,  are  the 
most  common.  Croupous  and  catarrhal  pneumonia  fre- 
quently complicate  the  severe  bronchial  inflammation  from 
which  so  few  patients  with  confluent  small-pox  escape. 

Vakiola  Hemoekhagica. — There  is  another  form  of 
small-pox  which  can  hardly  be  regarded  as  a  distinct  variety, 
but  rather  as  a  modification  of  those  varieties  which  have 
just  engaged  our  attention,  and  which  has  been  called  liem- 
orrhagic  variola.  It  differs  from  the  varieties  already  de- 
scribed, not  in  the  manner  of  its  development  as  far  as  the 
initial  fever  is  concerned,  but  in  the  appearance  of  the 
eruption.  This  hemorrhagic  tendency  is  often  manifested 
as  early  as  the  first  appearance  of  the  eruption,  by  the  dark 
color  which  the  eruption  assumes.  Sometimes  the  papules 
become  hemorrhagic  from  the  very  moment  of  their  devel- 
opment ;  at  other  times  they  first  become  vesicles,  and  then 
become  hemorrhagic.      Again,   at  other  times,  the  hemor- 


PIFFEllKXTIAL    niAONOSIS.  283 

rhago  lirst  shows  itself  aft»'r  tlu^  vesicles  become  pustules. 
In  some  cases  the  eruption  over  the  whole  bod}-  becomes 
hemorrha<i;ic  ;  in  other  cases  it  is  lirnioiihagic  in  spots. 
In  the  majority  of  the  cases  of  this  variety,  however,  the 
ern])tii>n  becomes  liemorrhagic  as  soon  as  the  papules  have 
attained  the  size  of  a  lentil,  and  the  hemorrhagic  change 
comes  on  slowl}', generally  comuK^ncing  upon  tlie  lower  ex- 
tremities. Petechije  and  ecchymoses  usually  appear  be- 
tween the  points  of  eruption,  if  the  small-pox  is  of  the 
discrete  variety. 

In  connection  with  the  hemorrhagic  eru])tion,  at  th<!  same 
time  you  will  have  hemorrhages  from  the  various  mucous 
membranes  of  the  body— from  the  mucous  membrane  of 
the  nose,  perhaps  from  the  bronchial  mucous  membrane, 
and  sometimes  large  ecchymotic  spots  may  be  seen  U])on 
the  mucous  surfaces  of  the  mouth  and  throat. 

It  is  rare  for  this  form  of  small-pox  to  reach  the  stage  of 
suppuration,  for  before  this  stage  is  reached  patients  with 
hemorrhagic  sinall-])OX  sink  and  die,  either  from  the  over- 
whelming influence  of  the  small-pox  poison,  or  from  the  ex- 
liaustiou  caused  by  extensive  hemorrhage. 

In  females  profuse  menorrhagias  are  of  frequent  occur- 
rence, and  often  are  so  extensive  as  to  endanger  life. 

During  the  initial  stage  of  this  variety  of  small-pox,  the 
constitutional  symptoms  do  not  dififer  from  those  which 
attend  the  develojuuent  of  the  other  forms  of  this  disc^ase. 
It  is  im]»ossible.  from  their  character  and  intensity,  to  pre- 
dict, with  any  ih'gree  of  certainty,  the  subsequent  develop- 
ment of  hemoirhagic  variola.  It  has  been  said  that  the 
pains  in  the  back  and  limbs  are  more  severe  ;  but  these  are 
not  sufficient  to  characterize  this  type  of  the  disease.  Fre- 
quentlv  the  fev<'r  of  invasion  is  exccMnlingly  violent,  while 
during  the  eruptive  ])eri()d,  and  during  tlu^  entire  subse- 
quent course  of  the  disease,  the  temperature  is  compara- 
tively low  ;  sometimes  during  the  entire  course  it  does  not 
rise  above  102' F.  In  striking  contrast  with  the  low  tem- 
perature is  the  frequency  of  the  ])ulse.  In  those  cases  in 
^^;hich  extensive  hemorrhages  have  occuired.  the  tem])eia- 
ture  often  falls  below  the  normal  standard,  while  the  pulse 


284  SMALL-POX. 

ranges  from  140  to  160,  and  is  exceedingly  feeble  in  charac- 
ter. Only  when  a  comparatively  few  of  the  vesicles  be- 
come hemorrhagic  does  the  case  terminate  in  recovery. 

Before  describing  the  modifications  of  small-pox  produced 
by  inoculation  and  vaccination,  I  will  complete  the  history 
of  those  varieties  which  have  already  engaged  our  attention. 

DiFFEREXTiAL  DiAGXOSis. — The  first  question  that  comes 
to  us  under  this  head  is,  How  early  can  small-pox  be 
recognized?  One  who  has  seen  very  many  cases  of  the 
disease  may  be  able  to  reach  a  diagnosis  on  the  third  day, 
that  is  the  first  day  of  the  eruption,  although  at  that  time 
there  is  nothing  characteristic  about  the  eruption  or  the 
ushering-in  symptoms.  It  is,  however,  better  and  safer  to 
wait  until  the  second  or  third  day  of  the  eruption  before 
committing  yourselves  to  a  positive  diagnosis,  for  there  is 
little  to  be  feared  from  infection  until  the  vesicles  are  fully 
formed ;  then  you  may  be  positive  in  regard  to  your 
diagnosis. 

The  exanthematous  fever  which,  in  its  early  stages,  and 
on  account  of  its  eruption,  is  most  liable  to  be  taken  for 
small-pox,  is  measles. 

Usually  the  eruption  of  measles  is  so  distinct  and  well 
defined  that  you  will  not  mistake  its  true  character ;  but 
there  are  cases  of  measles  in  which  the  eruption  presents  an 
appearance  closely  resembling  the  first  appearance  of  the 
eruption  of  small-pox.  Such  cases  are  not  altogether  infre- 
quent. A  number  of  cases  of  measles  came  under  my  ob- 
servation while  in  the  Small-pox  Hospital  that  had  been 
sent  by  physicians  to  the  hospital  as  cases  of  small-pox. 

If  you  defer  making  a  diagnosis  until  tlie  vesicles  are 
fully  developed,  you  need  make  no  mistake  of  this  kind. 

In  measles  there  is  cotyza,  a  cough,  sneezing,  redness  and 
suffusion  of  the  eyes.  These  symptoms  are  not  present  in 
small-pox. 

In  small-pox,  wiien  the  stage  of  eruption  is  reached,  the 
temperature  falls ;  while  in  measles,  when  the  eruption 
appears,  the  temperature  continues  to  rise.  The  range  of 
temperature  is  higher  in  small-pox  than  in  measles.  In 
these  respects  the  two  diseases  differ  sufficientlj^  to  enable 


DTFFKrvKN'lIAL    DI  AC  X<  »SIS.  285 

yoii  to  make  a  diirrrriitial  diagnosis.  A<;ain,  if  you  wait 
until  the  vesicles  brconu'  iUMl)ili('at»'(l,  it  will  hardly  Ix^ 
possible  that  you  slioiiM  inaki'  a  luistak''  in  dia<^n().sis. 

PminLC  the  jx-riod  of  initial  fever  it  is  })()ssible  to  nnstako 
sniall-i)o\'  for  ty]>lius  fm-cr.  Tn  both  diseases  then.'  may  1x3 
delirium,  ]»ain  in  the  head,  veirii^o.  hi^h  temperature,  and 
evidence  of  great  distui])an('e  of  the  nervous  system.  I 
know  of  no  symptom  which  will  enable  you  to  make  a 
positive  diagnosis  during  the  ver}^  early  period  of  the  dis- 
ease. Of  course,  if  typlius  fever  is  prevailing,  or  if  small- 
pox is  prevailing,  and  the  patient  has  been  exposed  to 
either  one  of  these  contagions,  you  will  be  able  to  make 
a  diagnosis  without  much  dithculty.  Usually  there  is 
greater  loss  of  muscular  power  in  typhus  fever  than  in 
small-pox,  but  this  symptom  is  not  always  well  marked. 
By  the  third  day,  the  appearance  of  the  eruption  upon  the 
face,  where  it  is  first  seen,  settles  the  question  of  diagnosis. 
The  eruption  of  typhus  fever  is  first  seen  upon  the  abdo- 
men, and  it  may  extend  over  the  whole  body  without 
appearing  on  the  face.  It  rarel}^  appears  before  the  fifth 
day  of  tlie  fever.  If,  therefore,  you  wait  until  the  eruption 
appears,  the  differential  diagnosis  between  small-pox  and 
typhus  fever  can  be  readily  made. 

Ml  hhtfjitis  is  another  disease  which  small-pox,  in  its 
initial  stage,  resembles.  I  have  seen  a  case  of  small-pox 
treated  for  several  days  as  a  case  of  meningitis.  TIkm-c  is 
always  considerable  cerebral  disturbance,  and  a  full,  hard, 
bounding  pulse  in  the  initial  stage  of  small-pox.  Photopho- 
bia and  intense  })ain  in  the  head,  as  also  nausea  and  vomit- 
ing, may  be  present  in  both  diseases.  Unless  it  may  be  the 
expression  of  the  face,  there  is  often  no  distinguishing 
mark  between  the  two  diseases  in  their  <'arly  stages.  Tn 
meningitis  there  is  usually  a  pale,  anxious  expn'ssion  of 
countenance,  whereas  early  in  small-po.\:  the  face  is  Hushed, 
and  day  by  day  the  fiush  deejjens  until  the  eruption  a]i])ears. 
There  is  often  a  uniform  redness  over  the  entire  surface  of 
the  body  in  confluent  small-pox  when  the  eruption  appears, 
or  at  least  that  portion  of  it  where  the  eruption  makes  its 
appearance. 


286  SMALL-POX. 

On  the  appearance  of  tlie  eruption  the  differential  diag- 
nosis between  tliese  two  diseases  is  readily  made.  I  wish 
to  impress  you  with  tlie  fact  tliat  it  is  miicli  better  to  wait 
in  all  doubtful  cases,  perhaps  in  every  case  of  small-pox, 
until  the  eruj^tion  appears  before  attempting  to  make  a 
diagnosis. 

It  is  an  unfortunate  occurrence  whenever  a  patient,  who 
is  not  sick  with  small -pox,  is  sent  to  a  small-pox  hospital, 
and  it  is  equally  unfortunate  whenever  a  small-pox  patient 
is  retained  in  a  family  or  neighborhood  a  sufficient  length 
of  time  to  expose  the  remaining  members  of  his  own  family 
or  other  families  in  the  neighborhood  to  the  contagion  of 
this  disease ;  but  there  is  little  danger  of  infection  until  the 
vesicles  are  fully  formed. 

ProgjSTOSis. — The  prognosis  in  any  case  of  small-pox  de- 
pends upon  the  amount  of  the  eruption  ;  the  more  abun- 
dant the  eruption,  the  greater  the  danger  to  life.  The  prog- 
nosis also  depends  upon  the  type  of  the  disease.  Unless 
some  complication  arises,  the  majority  of  cases  of  discrete 
small-pox  recover  ;  while  of  continent  small-pox,  which  is  a 
much  graver  disease,  nearly  one-half  the  cases  prove  fatal. 

The  best  record  obtained  in  the  Small-pox  Hospital  on 
the  island  was  one  death  in  every  five  cases.  In  the  hemor- 
rhagic variety,  whether  discrete  or  confluent,  a  fatal  termi- 
nation is  almost  inevitable.  Only  a  very  few  cases  of  the 
hemorrhagic  variety  recover,  and  when  recovery  does  take 
place  it  is  only  reached  after  the  patient  has  passed  through 
an  apparently  fatal  condition  of  coma. 

The  ratio  of  mortality  is  always  lower  at  the  end  than  at 
the  beginning  of  an  epidemic.  It  is  more  fatal  in  the  sum- 
mer than  in  the  winter. 

The  age  of  the  patient  greatly  influences  the  prognosis. 
In  infancy  and  in  extreme  old  age  the  ratio  of  mortality 
reaches  its  maximum.  Among  adults,  the  prognosis  is 
worse  in  females  than  in  males.  In  the  intemperate  the 
prognosis  is  always  bad,  for  with  this  class  of  persons  the 
disease  is  liable  to  assume  a  hemorrhagic  type.  The  intem- 
perate die  in  discrete  small-pox  when  the  temperate  wdll 
with  almost   certainty   recover.      In  the  overworked  and 


badly-iiourislu'd  tlie  prognosis  is  luid.  Robust  and  h.":ill  liy 
persons  ]kiss  tlirough  a  seven^  t3^pe  of  the  disease  nnicli 
more  safely  tlian  those  enfiM'l.l.'d  hy  syphilis  and  oth.-r 
chronic  forms  of  the  disease. 

The  severity  of  the  fever  of  invasion  is  not  a  safe  guide 
in  jirognosis.  Sometimes  a  severe  initial  stage  prec(xles  a 
mild  form  of  the  disease  ;  sometimes  patients  with  this  dis- 
ease pass  into  a  state  of  complete  unconsciousness,  remain 
in  that  (■onditi(Mi  for  some  time,  then  the  eruption  begins  to 
change  in  color,  and  linally  recovery  takes  place.  Such 
cases,  however,  are  exceptional. 

However  well  (hn-eloped  the  eruption  may  be,  or  however 
well  tilled  the  vesicles,  you  must  remember  that  the  eighth 
day  is  the  commencement  of  the  suppurative  fever,  which 
is  the  period  of  the  greatest  danger.  Upon  this  day  you  may 
find  your  patient  ]Kissing  into  a  state  of  collapse,  the  result  of 
the  depressing  intluence  ui)on  the  nervous  system  produced 
by  the  large'  extent  of  surface  involved  in  the  suppura- 
tive process.  If  patients  do  not  die  until  the  second  week 
of  the  disease  in  most  cases  the  fatal  result  is  due  to 
exhaustion,  although  death  may  occur  from  complications. 
Usually  they  pass  into  a  typhoid  condition,  the  result  of 
the  excessive  drain  upon  the  system  wliile  the  supi)urative 
process  is  going  on.  Secondary  syphilis  is  occasionally 
developed  during  the  period  of  desiccation.  All  such 
cases  that  have  come  under  my  observation  have  proved 
fatal.  Tlie  most  frequent  complications  wliich  cause  death 
are  those  which  occur  in  the  throat  and  air-])assages. 
In  some  instances  swelling  of  the  glands  of  the  neck  and 
mucous  membrane  of  the  throat  takes  place  to  such  an  ex- 
tent as  to  seriously  interfere  with  deglutition  and  resjiiration. 
AVhen  this  occurs  it  becomes  a  great  element  of  danger,  and 
mattM-ially  affects  your  prognosis.  The  tongue  may  become 
swollen  to  such  an  extent  that  the  patient  will  be  unable  to 
])rotrude  it,  or,  being  able  to  protrude  it,  will  not  be  able  to 
retract  it.  Under  such  circumstances  deglutition  is  almost 
impossible,  and,  as  I  have  already  stated,  oedema  glottidis  is 
Mable  to  occur.  You  may  have  laryngeal  ulceis.  and  ulcers 
occurring  in  the  trachea  and  in  the  bronchial  tubes.     These 


288  SMALL-POX. 

may  give  rise  to  clianges  wliich  will  so  interfere  witli  respi- 
ration as  to  cause  the  death  of  tlie  patient.  Death  may 
also  occur  from  general  bronchitis  or  pneumonia.  Perhaps 
the  most  dangerous  complication  is  acute  fatty  degenera- 
tion of  the  kidney.  Whenever,  in  the  course  of  the  disease, 
the  urine  becomes  scanty  and  high-colored,  but  especialy 
when  it  becomes  so  at  the  commencement  of  the  secondary 
fever,  you  may  then  be  certain  that  you  have  kidney  com- 
I)lication.  Under  these  circumstances  your  patient  may 
pass  into  a  condition  in  which  convulsions  will  be  devel- 
oped, and  coma  and  death  ensue. 

Before  leaving  this  subject  I  will  call  your  attention  to  a 
case  of  confluent  small-pox  which  came  under  my  observa- 
tion about  one  month  ago.  I  make  mention  of  this  case 
that  I  may  impress  upon  you  the  importance  of  one  symp- 
tom as  regards  prognosis,  that  is,  the  abundance  of  the 
eruption. 

I  was  called  in  to  visit  a  gentleman  who  v/as  in  the  initial 
stage  of  the  disease.  I  liad  charge  of  him  up  to  the  third 
day  of  his  illness.  At  that  time  an  abundant  small-pox 
eruption  had  made  its  appearance.  He  then  passed  into  the 
hands  of  a  younger  physician,  who  seemed  amazed  when  I 
said  to  him  that  I  thought  the  patient  would  die.  A  few 
days  later  the  physician  informed  me  that  the  patient  was 
doing  well,  and  he  thought  I  had  made  haste  in  my  progno- 
sis. In  reply  I  said,  "  wait  until  the  nintli  day."  Upon  the 
eiglitli  day  I  saw  my  professional  brother  again.  He  then  re- 
marked that  the  patient  was  very  much  worse,  and  he  was 
afraid  he  was  going  to  die.  He  died  a  short  time  after  our 
last  conversation.  ^N'ow,  the  only  symptom  which  led  me  so 
early  to  make  an  unfavorable  prognosis  was  the  abundance 
of  tlie  eruption. 

In  the  hemorrhagic  variety  of  small-pox  usually  the  stage 
of  suppuration  is  not  reached— the  patient  dies  before  that 
period  on  account  of  the  extensive  changes  which  take 
place  in  the  blood.  Under  such  circumstances  you  are  lia- 
ble to  have  complete  suppression  of  the  urine,  or,  at  least, 
suflficiently  complete  to  give  rise  to  ursemia  in  addition  to 
the  small-pox  poisoning. 


TREATMENT.  289 

Tkkatmext. — We  now  come  to  the  treatment  of  small- 
pox. Tlu'  lirst  question  that  arises  under  this  head  is, 
liave  we  any  means  by  whicli  we  can  arrest  its  devel()j)ment 
after  the  initial  fever  has  been  established  i  In  vaccination, 
pi-o})erh'  ])erf(H'med,  we  undoubtedl}'  ])()ssess  a  means  by 
which  we  may  prevent  one  from  contraction  of  the  disease 
when  exposed  to  its  infection. 

But  the  question  now  arises,  have  we  any  power  to  arrest 
the  develo]unent  or  niitiii,ate  the  severity  of  the  disease  after 
the  initial  fever  is  established^  No  reliable  alliiinativc  an- 
swer has  been  iriven  to  this  question.  It  has  been  ])roj)osed 
to  accomplish  this  by  blood-letting,  emetics,  diaphoretics, 
purgatives,  cold-baths,  and  more  recently  by  the  subcutane- 
ous injection  of  tlie  vaccine-virus..  All  of  these  means  have 
been  tested  and  have  failed  toaccom})lish  the  desired  result. 

The  assertion  that  large  doses  of  quinine,  given  during 
the  stage  of  invasion,  will  shorten  the  duration  and  modify 
the  course  of  the  disease  is  verified  only  by  the  experience 
of  its  author. 

Quite  recently,  it  has  been  claimed  tliat  carbolic  and  sali- 
cylic acid  will  destroy  the  septic  poison  of  variola,  and  thus 
shorten  and  modify  its  course.  My  own  experience  as  re- 
gards their  use  has  not  been  sufficient  to  decide  the  ques- 
tion for  myself,  but  I  am  unable  to  find  any  statistics  whicli 
sustain  such  an  assertion. 

During  the  fever  of  invasion  all  that  you  can  do  is  to 
treat  special  sjnnptoms. 

Place  the  patient  in  bed  in  a  large,  well-ventilated  a])art- 
ment ;  if  possible  keep  the  temjjerature  of  the  room  below 
60°  F.  I  remember  that,  in  the  Small- ]iox  Hospital,  those 
patients  did  best  who  were  ]>laced  in  barracks  which  were 
so  open,  that  frequently,  during  the  winter  months,  when  I 
made  my  morning  visit,  I  would  find  little  snow-drifts  on 
tht'  floor  between  the  beds. 

When  the  body  temperature  ranges  ns  high  as  ]()7^  F.  or 
108°  F.,  it  may  be  necessary  to  e^nploy  cold  to  the  surface, 
and  to  give  antipj'retic  doses  of  (piinine  to  reduce  the  tem- 
perature. If  the  headache  is  severe  and  the  face  flushed, 
iced  compresses  and  ice-bags  to  the  head  will  usuallv  afTord 
19 


290  SMALL-POX. 

relief,  K  tlie  vomiting  is  severe  and  constant,  iced  carbonic 
acid  water  may  be  given,  and  if  tlie  vomiting  is  attended 
by  great  restlessness,  hypodermic  injections  of  morphine 
are  indicated.  Administer  siicli  food  as  can  be  readily  as- 
similated. I  have  found  nothing  better  than  iced  milk  and 
seltzer  water.  If  the  bowels  are  constipated  it  is  well  to 
relieve  them  by  enemas  of  cold  water. 

In  those  cases  in  which  the  eruption  is  tardy  in  making 
its  appearance,  and  the  temperature  is  higher,  sometimes,  if 
the  patient  is  kept  in  a  warm  bath  for  fifteen  or  twenty 
minutes,  the  development  of  the  eruption  is  hastened. 

When  the  eruption  has  appeared,  the  measures  to  be  em- 
ployed will  vary  with  the  character  of  the  eruption.  The 
milder  forms  of  discrete  variola  require  no  interference.  In 
the  severer  forms  the  attendant  symptoms  will  decide  the 
means  to  be  employed. 

Sooner  or  later,  sometimes  ver}^  early  in  the  severer  forms 
of  the  disease,  you  will  find  3^our  patient  sinking  from  the 
depressing  effects  either  of  the  small-pox  poison  or  of  the 
suppurative  process  which  is  taking  place  upon  the  surface 
of  the  body.  Under  such  circumstances  you  will  be  com- 
pelled to  resort  to  the  use  of  stimulants.  There  is  no  ques- 
tion but  that  the  free  use  of  stimulants  for  a  few  days,  just 
at  the  period  of  suppuration,  in  very  many  cases  does  much 
to  save  life.  At  this  time  you  may  find  your  patient  with 
a  dry  tongue,  a  frequent,  feeble  pulse,  blue  lips  and  finger 
ends,  giving  evidence  that  he  is  rapidly  passing  into  a  state 
resembling  that  met  with  in  the  latter  stages  of  typhoid 
fever.  Active  delirium  is  frequently  present ;  the  patient 
insists  upon  getting  out  of  bed.  Under  these  circumstances, 
the  life  of  your  patient  will  often  be  saved  by  the  judicious 
use  of  stimulants.  If  the  delirium  is  excessive,  hypodermics 
of  morphine  may  be  combined  with  the  administration  of 
stimulants.  During  the  stage  of  desiccation,  warm  baths 
employed  every  day,  or  every  other  day,  give  great  comfort, 
and  assist  in  the  falling  of  the  crust.  After  the  baths,  the 
surface  should  be  freely  oiled. 

Complications  will  be  treated  according  to  the  general 
rules  which    ";overn  their  treatment.      If   abscesses   occur 


TltKATMENT.  201 

in  the   sulx-utaiit'oiis  (is.sii<>,    tlu'V   should   early  be   freely 

OJH'IK'd. 

We  aiT  ])()\vt'r]('ss  wlit-n  we  coint'  to  dca!  wiili  lln'  licmor- 
rliagic  form  of  siiiall-i)()\.  A1iIi(iiil;1i  tonics  and  st  iiiiiilaiits 
have  been  hiulily  r«'ConiMifiidfd,  they  tlo  little  i^ood.  Tiaiis- 
fiisioii  has  been  juoposcd  and  ))ra('tist'd  with  no  dclinite 
results.  If  till'  inoulli  and  jtliarv  iix  ari'  vci-y  iniicli  iii\o|\rd, 
and  there  is  dillicully  in  dt',«;lulirion,  iee-cold  caibonaled 
water  with  a  weak  solution  of  niur,  tinct.  ferri  used  as  a 
garuli'  will  often  give  great  relief.  Sometimes  the  stronger 
anlis(-])tic  gargles,  such  as  carbolic  acid  and  i)erraanganate 
of  ]iotash,  will  be  of  service. 

There  is  still  one  point  in  the  treatment  of  sniall-])ox 
which  is  deserving  of  attention,  and  that  is,  what  means 
may  be  employed  to  prevent  the  ])itting,  es])ecially  upon 
the  face,  which  is  so  fi-equent  an  accompaniment  or  the  re- 
sult of  small-pox  ?  As  I  have  already  stated,  the  erui)tion 
first  makes  its  a])pearance  upon  the  face;  there  it  is  usually 
most  abundant,  and  is  most  liable  to  be  followed  by  pitting, 
and  there  it  passes  more  quickly  through  all  its  stages  than 
upon  any  other  part  of  the  body.  In  order  to  prevent  the 
pitting,  it  has  been  proposed  by  some  to  exclude  light  and 
air  from  the  surface  covered  by  the  eruption.  For  this  pur- 
pose a  great  many  substances  have  been  employed,  such 
as  collodion,  gutta-})ercha,  certain  forms  of  ])laster,  li(|uid 
paper,  etc.,  etc.  All  these  substances  are  to  be  so  applied 
as  to  form  a  mask  for  the  face,  which  should  c()m])letely 
exclude  light  and  air  from  the  surface. 

You  will  recollect  that  I  stated  that  the  pitting  was  due 
to  the  formation  of  a  slough,  and  that  the  slough  was  seated 
in  the  areolar  tissue,  and  that  if  by  any  means  you  can  so 
interfere  with  the  inflammatory  process  as  to  prevent  the 
formation  of  a  slough,  you  will  ])revent  the  i)itting.  It  was 
claimed  by  those  who  advanced  the  theory,  that  excluding 
light  and  air  prevented  i)itting  ;  that  it  did  this  i)y  ])r«.^veut- 
ing  the  occurrenci-  of  sloughing. 

At  the  time  wIh-u  I  had  charge  of  so  many  sniall-]>o\  ])a- 
tients,  1  look  ])ains  to  test  all  tliosr  ;i]t{tlicaiions,  whi<-li  at 
that  time  had  l)een  and  are  still  lecomniended  for  that  })ur- 


292  SMALL-POX. 

pose,  and  I  satisfied  myself  that  about  the  same  results  were 
obtained  in  the  use  of  every  remedy,  and  in  no  case  was  pit- 
ting prevented.  Certain  j)atients  were  much  more  scarred 
than  others,  but  that  was  the  natural  result  of  the  disease. 
Some  have  proposed  to  coagulate  tlie  serum  in  each 
vesicle  by  means  of  iodine  or  nitrate  of  silver,  and  so  arrest 
the  inflammatory  process  and  prevent  pitting.  But  the  use 
of  these  means  has  been  attended  by  the  same  unsatisfactory 
results.  The  only  means  which  I  found  of  certain  value 
was  simple  cold-water  dressing  applied  over  the  face,  after 
having  ruptured  each  vesicle  before  it  became  a  pustule. 
In  this  way,  I  was  able  to  diminish  the  intensity  and  extent 
of  the  inflammation.  This  plan  of  treatment  I  adopted  in 
twenty  cases  of  confluent  small-pox,  and  it  not  only  gave 
the  patients  very  great  comfort,  relieving  them  to  a  certain 
extent  from  the  intense  itching,  thus  avoiding  rupture  of  the 
vesicles  by  scratching,  but  in  not  a  single  case  that  recovered 
was  there  bad  pitting.  In  the  treatment  of  small-pox,  the 
prevention  of  pitting  is  of  greatest  importance  to  a  certain 
class  of  patients,  especially  young  unmarried  females. 


LECTURE    XXV. 


SMALL-POX 


Treatment    {continued).  —  Inoculation.  —  Vaccination.  — 

Varioloid. 

^VE  will  now  consider  the  two  recognized  methods  for 
rendering  small-pox  poison  so  innoxious  that,  when  one  has 
been  exposed  to  its  influence^  he  will  be  perfectly  safe  from 
infection.  These  two  methods  are  known  as  inoculation 
and  vaccination. 

Inoculation  was  first  introduced  into  En,ij;land  in  the  year 
1781,  by  Lady  Montague,  who  first  practised  it  upon  her 
own  child,  slir  having  become  familiar  with  the  practice 
while  travelling  in  Italj',  wlicre  the  practice  undoubttnlly 
originated.  Subsequently  it  was  quite  generally  i)ractised 
throughout  Great  Britain.  Pus  from  a  small-pox  pustule 
was  introduced  beneath  the  epidermis  of  one  wlio  had  been 
prepared,  by  diet  and  general  liygienic  measures,  for  the 
safe  development  of  the  disease.  It  was  claimed  that  the 
disease  resulting  from  inoculation  was  a  modified  small- 
pox, differing  from  the  original  disease  in  that  it  ran  its 
course  more  rapidly,  was  attended  b}^  the  formation  of  a 
fewer  number  of  pustules — perhaps  no  more;  than  twenty 
or  thirty  upon  the  entire  body— and  was  said  to  rarely 
terminate  fatally,  the  ratio  of  mortality  being  about  one  in 
one  hundred.  The  patient  who  had  the  disease  in  this 
manner  was  equally  protected  with  those  who  had  the 
disease  in  the  ordinary  manner,  being  exempt  from  a 
second  attack. 


294  SMALL-POX. 

The  disease  developed  by  inoculation  passed  tlirougli  the 
regular  stages  of  a  case  of  ordinary  small-pox — tliat  is, 
there  was  the  iiiitial  fever,  the  eruption,  and  the  desicca- 
tion, one  stage  following  another  in  regular  succession. 
This  procedure  was  found  more  or  less  unsatisfactory,  for 
it  had  its  disadvantages  ;  there  was  danger  in  it,  and  inocu- 
lated persons  could  communicate  small -pox  to  others. 

During  the  latter  part  of  the  last  century.  Sir  William 
Jenner  observed  that,  in  some  of  the  northern  counties  of 
England,  persons  employed  in  dairies,  who  suffered  from  a 
certain  form  of  ulcer  upon  the  hands,  did  not  contract 
small-pox  when  exposed  to  the  influence  of  its  poison.  He 
also  found  that  these  ulcers  found  upon  the  hands  resem- 
bled pustules  found  upon  the  udder  of  the  cow,  and  seemed 
to  have  been  caused  by  contact  with  them.  Jenner  made 
a  thorough  investigation  of  the  subject,  and  arrived  at  con- 
clusions sufficiently  satisfactory  to  himself  to  warrant  the 
experiment  of  taking  matter  from  one  of  these  pustules 
found  upon  the  udder  of  the  cow  and  introducing  it  into 
the  arm  of  an  individual  who  was  supposed  to  be  unpro- 
tected from  tlie  contagion  of  small-pox.  After  the  sore 
upon  the  arm  had  run  its  course,  he  exposed  the  individual 
to  the  infection  of  small-pox,  and  in  this  way  he  estab- 
lished its  protecting  power. 

His  first  experiment  was  made  in  the  year  1791 ;  but  it 
was  not  until  six  years  afterwards  that  the  experiment  was 
repeated  by  any  other  person.  During  these  six  years  it 
is  probable  that  no  member  of  the  profession  ever  received 
more  anathemas  or  more  scurrilous  abuse  than  did  Jenner. 
He  was  attacked  by  the  leading  physicians  and  surgeons 
of  Great  Britain,  and  persecution  and  ridicule  so  followed 
him,  that  placards  with  caricatures  of  Jenner  were  posted 
throughout  the  streets  of  London  and  the  principal  towns 
of  Great  Britain. 

Jenner  kept  steadily  at  work  and  repeated  his  experi- 
ments, until  he  became  fully  convinced  that  by  vaccination 
perfect  protection  could  be  obtained  against  small-pox. 
Within  the  short  space  of  six  years  Jenner  compelled  the 
profession  to  admit  his  statements  and  adopt  his  practice, 


YArrTXATTOV,  205 

and.  within  the  fivo  or  six  years  followin^^  its  first  n^n^fr. 
nition,  th«'  ]M-actice  of  vaccination  b.M-amr  uniTornily  recog- 
nized and  practised. 

\'accination  was  introduced  into  this  country  in  the  year 
1802,  by  two  Boston  physicians,  and  it  very  soon  l)ecaine 
the  practice  of  the  entire  profession.  At  the  present  time 
tlK're  is  no  question  among  tlie  intellig,.nt  portion  of  tlie 
profession,  but  that  vaccination,  properly  pcrrornied,  is  a 
perfect  protection  against  tlie  infection  of  small-pox ;  if 
persons  contract  small-pox  after  they  have  been  vaccinated 
you  may  infer  it  has  not  been  properly  performed.  We 
have  no  other  means  of  protection. 

We  will  now  study  the  subject  of  varrinnfion.  There 
are  two  methods  of  performing  it.  One  method  is  to  take 
the  cirus  directly  from  the  cow,  this  is  called  hovine  virus ; 
the  other  method  is  to  take  the  virus  from  a  vesicle  de- 
veloped upon  the  human  body,  perhaps  a  vesicle  removed 
from  the  original  by  several  vaccinations,  this  is  called 
liumanized  virus.  It  has  been  a  common  practice  to  us(^ 
virus  taken  from  a  vesicle  that  was  removed  from  the 
original  vesicle  by  two,  five,  ten,  twenty  or  even  forty 
vaccinations,  on  the  supposition  that  just  as  perfect  pro- 
tection was  afforded  as  though  the  vaccine  was  taken 
directly  from  the  cow. 

Within  a  few  years  it  has  been  found  that  such  a  large 
projxtrtion  of  the  population  were  not  protected  from  the 
infection  of  small-pox,  and  that  cases  of  small-pox  were  so 
markedly  increasing  in  nunibei-.  that  a  retuin  has  been 
made  to  the  horirie  virus.  To-day,  this  foi-ni  of  virus  is 
used  by  a  majority  of  the  profession.  I  use  it  Ixn-ause 
when  I  obtain  a  perfect  vesicle,  alN-r  its  introduction  into 
the  svstem  T  am  convinced  that  tlu,^  person  is  thoroughly 
protected  against  the  infection  of  small-pox  poison.  T  never 
liave  this  assurance  when  I  use  the  humanized  virus. 

Dr.  .Tenner  found  that  there  were  several  pustules  de- 
veloped on  the  udder  of  the  cow,  which  closely  resembled  each 
other,  but  that  only  one  contained  the  \\y\\<  wliich  afforded 
protection  from  small-]iox.  In  obtaining  bovine  virus  it  is 
of    the   greatest    importance    that    the   genuine   vesicle   be 


296  SMALL-POX. 

sol(>ctod.  In  ordin*  to  make  the  selection  it  is  necessary  one 
should  be  familiar  with  the  peculiarities  of  each  variety. 

Dr.  F.  B.  Foster  and  Dr.  E.  H.  Pardee,  of  this  city,  have 
given  this  subject  much  study,  and  their  experience  and 
facilities  enable  them  to  furnish  bovine  virus  which  is  per- 
fectly reliable. 

If  humanized  virus  is  used,  not  only  is  the  protection  less 
certain  and  less  permanent,  but  there  is  danger  of  intro- 
ducing into  the  system  the  infection  of  other  diseases.  I 
have  in  my  possession  facts  which  prove  beyond  the  possi- 
bility of  a  doubt  that  syphilis  can  be  conveyed  from  one 
person  to  another  by  vaccination.  In  two  instances,  which 
came  under  my  own  observation,  it  was  so  conveyed  when 
the  humanized  vaccine  lymjDh  was  employed. 

Cutaneous  eruptions  may  also  be  conveyed  by  humanized 
vaccine  virus,  which  may  cause  the  development  of  very  ex- 
tensive and  serious  cutaneous  diseases. 

Again,  it  must  be  remembered  that  if  any  chronic  or 
acute  skin  disease  exists  at  the  time  the  vaccine  vesicle  is 
running  its  course,  the  protective  power  of  the  vaccination 
will  be  altogether  destroyed  or  very  greatly  modified. 

In  obtaining  vaccine  virus  for  use,  both  the  bovine  and 
the  humanized  virus  should  be  taken  from  the  vesicle  on  the 
eighth  day.  The  lymph  should  be  taken  from  the  vesicle 
before  the  inflammatory  process  has  commenced  which  is  to 
change  it  into  a  pustule.  A  few  years  ago  it  was  the  common 
practice  in  this  city  to  use  the  vaccine  crusts,  but  this  prac- 
tice has  fallen  almost  entirely  into  disuse  because  of  the 
great  danger  of  transmitting  disease  from  one  individual  to 
another. 

Always  use  the  bovine  virus  when  it  is  possible  to  obtain 
it.  If  compelled  to  use  the  humanized  virus,  use  the  lymph. 
You  must  puncture  the  vesicle  in  such  a  manner  that  the 
lymph  cannot  be  contaminated  by  the  blood  ;  this  is  best 
clone  by  introducing  your  instrument  parallel  wdth  the  arm. 
The  lymph  which  flows  from  such  a  puncture  can  be  pre- 
served upon  the  convex  surface  of  a  piece  of  quill,  and  con- 
veyed from  one  individual  to  another.  Vaccine  virus  se- 
cured from  the  human  arm  in  this  manner  is  less  liable" 


VACCIXA'I'IOX.  207 

tli;m  any  otlitM- form  of  liuin:niiz<Ml  virus  to  do  ])«'iinaiirrit 
lianii  to  tilt'  vacciiKiti'd  individual. 

The  vaccine  virus  is  usually  introducrd  hy  sfaril'yinu^  the 
surface,  so  as  to  redden  it,  scarcely  drawiui,^  blood;  llh-n 
the  surface  of  the  quill  containing'  the  virus  is  ai)plied  to 
the  scarified  part,  or  the  lynii)li  is  conveyed  from  one  to  tlie 
other  l>y  direct  transmission.  The  operation  is  sim]>le,  and 
one  with  which  you  are  doubtless  familiar.  It  is  not  neces- 
sary for  me  to  say  anything  in  regard  to  the  manner  of 
performing  it. 

Any  irregularity  in  the  development  of  the  vesicle  de- 
stroj's  in  a  greater  or  less  degree  its  protecting  power. 

When  an  individual  has  been  previously  vaccinated,  it  is 
liable  to  run  an  irregular  course.  A  primary  vaccination, 
such  as  the  first  vaccination  of  a  child,  should  pass  throuffh 
the foUoiolng  regular  stages  ;  if  it  does  not.,  it  fails  in  its 
protecting  poicer  :  Upon  the  third  day  after  the  introduc- 
tion of  the  virus  you  will  notice  at  the  point  where  it  was 
introduced  a  little  red  spot.  By  the  fourth  day  this  little 
red  spot  will  be  occupied  by  a  vesicle,  and  at  the  commence- 
ment of  the  fifth  day  you  will  begin  to  see  around  the 
vesicle  a  little  yellow  margin.  Xow  you  liave  a  vesicle  with 
a  yellowish- white  margin  at  its  base.  This  vesicle  goes  on 
increasing  in  size  up  to  the  eighth  day,  when  you  will 
notice  that  it  has  become  umbilicated,  and  that  there  is 
around  it  a  distinct  areola.  Previousl}'  there  has  been  a 
trilling  areola  present ;  now  it  becomes  very  distinct.  The 
vesicle  is  free  from  inflammation,  and  now  is  the  time  to 
take  the  lym])h  for  the  purpose  of  vaccination,  for  the 
vesicle  is  comi)lete.  The  lymph  should  l)o  taken  only  a 
short  time  before  using  it.  Now  a  change  is  to  take  place 
in  the  vesicle,  and  l)y  the  n»^xt  day  you  will  notice  that  tin; 
areola  has  extended,  ])erliaps  so  as  to  m<'asure  an  inch  in 
diameter;  this  areola  goes  on  extending  itself  through  tlie 
ninth,  tenth,  and  eleventh  days,  when  it  will  have  reacln'<l 
its  maximum  extent,  which  may  be  one  or  two  inches  from 
the  vesicle  in  all  directions.  It  is  now  of  a  deep  red  color. 
The  part  over  which  the  areola  has  sj)read  is  more  or  h'ss 
elevated,  the  arm  is  considerably  swullfu  and  })ainful,  and 


298  SMALL-POX. 

the  adjacent  glands  more  or  less  enlarged,  and  tender  to 
the  touch.  Tlie  extent  of  the  enlargement  of  the  gland 
adjacent  to  the  vaccine  vesicle,  the  axillary  gland,  if  the 
vesicle  is  upon  the  arm,  the  inguinal,  if  it  is  upon  the 
thigh,  varies  considerably  in  different  persons.  In  some  it 
is  very  great,  in  others  it  is  scarcely  noticeable. 

The  maximum  degree  of  inflammation  in  the  vesicle  has 
now  been  attained,  and  there  is  a  distinct  infiltration  of  the 
tissue  about  it.  On  the  twelfth  or  thirteenth  day,  the  red 
areola  begins  to  decline,  the  swelling  diminishes,  and  the 
vesicle,  or,  more  properly  speaking,  the  pustule,  ruptures, 
and  the  contents  escape.  The  rupture  belongs  to  the 
natural  course  of  the  vaccine  vesicle,  and  is  independent  of 
mechanical  violence.  From  this  time  the  inflamed  areola 
becomes  less  and  less  distinct,  and  by  the  fourteenth  or  fif- 
teenth day  the  crust  has  assumed  a  dark,  brownish  appear- 
ance, which  goes  on  deepening,  until  you  find  on  the 
seventeenth  day  a  deep-brown  crust  having  a  central  de- 
pression and  no  areola  of  inflammation.  It  may  be  attached 
to  the  surface  only  in  one  or  two  places,  and  can  be  readily 
removed  ;  if  permitted  to  remain,  usually  it  falls  off  on  the 
eighteenth  day.  This  is  the  course  pursued  by  a  perfect 
vaccine  vesicle.  The  shape  and  size  of  the  crust  will  cor- 
respond to  the  shape  and  size  of  the  vesicle,  and  in  this  way 
you  will  be  able  to  determine  whether  the  vesicle  has  or  has 
not  pursued  a  regular  course.  Of  course,  the  crust  will 
vary  in  shape  according  to  the  vaccination  ;  if  you  make 
an  irregular  scarification,  you  may  expect  an  irregular 
crust,  for  you  will  have  an  irregular  vesicle.  If  the  virus 
is  introduced  at  a  single  point,  the  vesicle  will  be  circular, 
and  the  crust  that  is  formed  will  also  be  circular,  and  oc- 
cupy the  exact  space  occupied  by  the  vesicle  ;  if  otherwise, 
it  is  evident  that  the  regular  course  of  the  vesicle  has  been 
disturbed. 

So,  also,  if  upon  the  eighth  day  you  find  a  pustule  instead 
of  a  vesicle,  you  may  be  certain  that  the  regular  course  of 
development  of  the  vesicle  has  been  disturbed,  and  complete 
protection  is  not  afforded  against  the  infection  of  small-pox. 

The  infiaramatory  process  around  the  vesicle  is  usually 


VACCIXATIOX.  200 

more  active  wlion  tlip  horiin'  ririfs  is  nscd,  (li:i?i  wIm-h  flic 
Jtumanizcil  rinis  is  intioduccd,  and  tli<*ro  is  nioic  constitu- 
tional disturbance.  Ordinarily,  during  the  development  of 
tlie  vaccint' vesicle  and  pustulf,  tli<M'(' is  hut  lit tlf  <'onstitu- 
tional  disturbance  ;  this  is  usually  self-limiting,  and  not 
sufficiently  severe  to  require  treatment.  About  the  eighth 
or  ninth  day,  the  person  vaccinated  may  ftvl  a  little  chilly, 
and  have  severe  headache ;  in  most  cases  there  is  a  slight 
rise  in  temperature. 

The  regular  course  of  the  vaccine  vesicle  may  be  inter 
fered  with  by  the  occurrence  of  an  erysipelatous  inflamma- 
tion, and  if  such  an  inflammation  does  occur  during  the 
course  of  its  development,  it  entirely  destroys  the  pro- 
tecting power  of  the  vaccination. 

Again,  if  a  large  quantity  of  pus  has  been  discharged, 
and  healing  of  the  ulcer  does  not  take  place  for  two  or  three 
months,  it  is  evident  that  something  besides  /7^«7///ie  vaccine 
virus  has  been  introduced  into  the  ann.  In  other  words, 
such  a  vaccination  has  not  pursued  a  regular  course  and  is 
not  protective.  As  I  have  already  stated,  the  presence  of  a 
vesicular  eruption  upon  the  surface  at  the  time  vaccination 
is  performed  will  interfere  with  its  development,  therefore 
I  would  advise  you  never  to  vaccinate  one  who  has  an  ec- 
zematous  eruption  U])on  any  part  of  the  body,  unless  he 
lias  been  exposed  to  the  contagion  of  small-pox,  for  it  is 
very  probable  that  the  vaccination  will  not  be  a  protective 
one. 

It  is  better  never  to  vaccinate  a  person  having  any  form 
of  skin  disease,  espcn-ially  if  the  eru])ti()n  is  vesicular  in 
character.  The  best  time  for  the  performance  of  vaccination 
is  in  infancy,  between  flie  tliird  and  fifth  months. 

Revaccination  should  bt»  ])i'rformed  after  ])uberty,  and 
always  after  or  preceding  a  new  exposure  to  the  contagion 
of  small-pox,  for  the  period  during  which  revaccination 
will  afford  ccmiplete  protection  is  not  the  same  in  each  in- 
dividual. In  some  cases  a  single  vaccination  will  afT(U'd 
complete  protection  for  a  lifetitne.  In  other  cases  it  ia 
necessary  to  frequently  repeat  the  vaccination,  jjcrhaps 
every  two  years,  in  ordei- to  <.'cnie  th.'  di'<in'd  protection. 


300  SMALL-POX. 

Xot  unfrequently  persons  are  astonished  when  the  re- 
vaccination  runs  a  regular  course,  for  they  suppose  them- 
selves perfectly  protected  against  the  contagion  of  small- 
pox. 

The  question  has  been  raised,  If  vaccination  be  performed 
previous  to  an  attack  from  any  severe  disease,  will  not  the 
protecting  power  of  the  vaccination  be  destroyed  by  that 
disease  ?   Certain  facts  seem  to  indicate  that  such  is  the  case. 

Again,  is  it  necessary  to  rejDeat  vaccination  in  order  to 
secure  its  protecting  power?  To  explain  my  meaning. 
There  is  no  question  but  that  a  child  may  be  repeatedly 
vaccinated,  and  after  each  vaccination  may  have  some  sort  of 
a  local  manifestation,  but  he  will  never  have  but  one  j)erfect 
vaccine  vesicle.  If  the  primary  vaccination  runs  a  regular 
course,  it  affords  protection,  and  the  second  introduction  of 
the  virus  seems  to  me  to  be  unnecessary,  as  it  simply  de- 
velops an  irregular  vaccine  vesicle.  Nor  does  the  introduc- 
tion of  the  virus  at  two  places  at  the  same  time  seem  to  be 
necessary,  for  one  perfect  vesicle  is  sufficient. 

The  next  question  which  presents  itself  is,  What  kind  of 
disease  is  that  which  is  developed  in  individuals  who  are 
protected  by  vaccination,  when  they  are  exposed  to  the  in- 
fection of  small-pox  ? 

Unquestionabl}^  it  is  a  modified  form  of  sraall-pox.  It 
has  received  the  name  of  varioloid. 

Yaeioloid. — This  is  a  disease — the  result  of  an  exposure 
to  the  contagion  of  small-pox — which  would  be  small-pox, 
had  the  person  exposed  to  this  contagion  never  been  vac- 
cinated. During  every  epidemic  of  small-pox  you  will  meet 
with  a  certain  number  of  cases,  concerning  which  you  will 
be  in  doubt  whether  to  call  them  cases  of  variola  or  vario- 
loid. Certain  persons  who  have  never  been  vaccinated,  on 
account  of  their  naturally  slight  susceptibility  to  the  infec- 
tion of  small-pox,  may  have  such  a  mild  form  of  variola 
that  it  is  difficult  to  distinguish  it  from  varioloid. 

There  are  certain  points  of  resemblance  between  varioloid 
and  variola,  and  there  are  certain  marked  differences.  Va- 
rioloid differs  from  small-pox  in  the  rapid  development  and 
decline  of  the  eruption,  in  the  small  number  of  the  ^Dustules^ 


v.vrjoLOTi>,  301 

and  ill  the  sliort  tiiuo  ivquircd  for  tlu"  formiilioii  and  sepa- 
ration of  the  crusts.  The  entire  jx'riod  of  tlie  ciiiptive 
stage  often  does  not  hist  more  than  a  week.  Rarely  are 
there  cicatrices  or  pits  aftri-  the  disappearance  of  th.-  niip- 
tion. 

In  vaii()h»id  and  viliiohi  ihc  pustulfs  ])ass  throUL;li  simi- 
lar stages.  We  lirst  havi^  the  small  red  spot,  then  vesicles 
form,  often  within  twelve  hours  after  the  ai)i)(,'arance  of  the 
eruption.  These  vesicles  rapidly  increase  in  size  ;  sometimes 
they  are  umhilicated  ;  by  tin '  end  of  the  third  day  their 
contents  sometimes  becomes  i)uruh'nt,  without  any  tume- 
faction of  the  surrounding  skin.  On  the  fifth  day  desicca- 
tion commences,  and  is  often  completed  b}^  the  seventh  day. 
The  majority  of  the  pustules  simply  dry  up,  without  pre- 
viously bursting,  forming  brown  crusts  which  are  thinner 
and  smaller  than  those  of  variola. 

In  varioloid  you  rarely  have  the  regular  period  of  devel- 
opment such  as  you  have  in  variola.  In  variola  there  is  the 
period  of  eruption,  during  which  the  vesicle  is  perfected  ; 
this  is  succeeded  by  the  period  of  suppuration,  then  by 
desiccation,  about  fourteen  days  being  required  to  complete 
the  process ;  while  in  varioloid  the  course  of  the  eruption 
is  irregular,  and  is  usually  completed  within  one  week. 

Again,  in  varioloid  there  is  but  little  constitutional  dis- 
turbance after  the  appearance  of  the  eruption.  It  ivseiii- 
bles  variola  in  the  severity  of  the  S3nnptonis  during  the 
period  of  invasion,  during  which  time  you  will  not  be  able 
to  determine  whether  the  case  is  one  of  varioloid  or  one  of 
sniall-])ox.  If  you  are  watching,  lest  sinall-i)o.\:  may  be 
developed,  then  you  may  be  led  to  susjiect  its  advent  from 
the  severe  pain  in  the  head  and  l)ack.  and  from  the  gem'ral 
febrile  disturbanc(?  following  an  exjjosure  to  the  infection 
of  small-],)0X  ;  l)ut  as  soon  as  the  eru])tion  a])])ears  there  is 
an  entire  cessation  of  all  the  active  febrile  symptoms.  Dur- 
ing the  period  of  invasion  varioloid  may  be  said  to  very 
closely  resemble  variola. 

When  an  individual  is  exposed  to  varioldid.  tlie  most 
severe  case  of  conlluent  sniall-])<»x  may  be  the  result.  This 
fact  proves  that  varioloid  is  a  modified  form  of  small-pox 


302  SMALL-POX. 

wliicli  has  been  produced  by  vaccination.  It  is  now  gener- 
ally conceded  that  varioloid  is  small -pox  having  a  shorter 
duration  and  a  milder  course  than  nsual. 

You  may  say  we  modify  small-pox  by  inoculation.  We 
do  not.  There  is  the  same  regular  development  of  the  dis- 
ease after  inoculation  that  we  have  in  the  ordinaiy  form  of 
small-pox  ;  we  only  modify  its  intensity  ;  while  by  vaccina- 
tion we  not  only  lessen  the  severity  of  the  disease,  but  we 
are  able  to  so  modify  the  stages  of  its  development  as  to 
shorten  its  duration. 

Prognosis.— Usually  the  prognosis  is  good.  The  diagno- 
sis is  readily  made.  The  rapidity  with  which  the  vesicles 
are  developed,  their  shorter  duration,  the  subsidence  of  the 
fever,  and  the  appearance  of  the  eruption,  together  with  the 
usual  duration  of  the  attack,  are  sufficient  to  distinguish  it 
from  variola. 

Treatment. — The  treatment  for  varioloid  is  the  same  as 
for  a  mild  or  modified  form  of  small-pox.  The  patient 
should  be  placed  in  a  large,  well-ventilated  room,  quaran- 
tined the  same  as  though  suffering  from  variola.  If  the 
form  of  invasion  is  severe,  saline  cathartics  may  be  admin- 
istered. When  delirium  is  present,  and  the  pain  in  the 
back  is  very  severe,  the  moderate  use  of  opium  is  admis- 
sible. 

As  soon  as  the  eruptive  period  of  varioloid  is  reached  no 
treatment  is  required;  the  patient  passes  on  to  a  rapid  and 
complete  convalescence. 

Before  leaving  the  subject  of  variola,  I  will  refer  to  a  few 
complications  which  do  not  belong  to  its  natural  history. 

As  I  have  already  stated,  there  really  is  no  dividing  line 
between  the  local  affections  of  this  disease  and  most  of 
its  complications.  Bronchitis,  more  or  less  severe,  accom- 
panies nearly  all  cases.  In  some  it  leads  to  catarrhal  pneu- 
monia, the  occurrence  of  which  is  always  attended  with 
danger.  Pleurisy  and  pericarditis  occasionally  occur  as 
serious  complications. 

Laryngeal  inflammations  are  a  part  of  its  history.  When 
the  laryngitis  is  accompanied  by  extensive  ulceration  of  the 
laryngeal  mucous  membrane,  or  when  acute  oedema,  of  the 


vAuioLoii).  :j()3 

glottis  is  (.h'vrl()])t>(l,  or  when  it  assiiinos  a  diplitlicritic  cliar- 
acter,  you  have  dt'vclojx'd  a  scries  of  coiii])li(;atioiis  which 
often  iiiiickly  (Irslroy  lif"'. 

Meiiiii^iiis  and  ('t'rrl)ral  coniplioations  are  not  of  common 
occunviicc  in  variohi,  althou^i^h  acute  menintritis  and  o'dema 
of  the  l)r;rni  do  sometimes  occur  ;  so  that  wlien  very  active 
delirium  or  sudilen  coma  come  on  durini^  the  erui^tive 
stai^e  of  the  disease  tliere  is  reason  to  fear  their  deveh)p- 
nient. 

A  severe  form  of  conjunctivitis  may  occur,  wliich  is  some- 
times attended  by  the  deveh)])ment  of  ])ustuh's  on  the  ]ki1- 
pebral  conjunctiva  ov  u\u)n  the  cornea.  Whiii  (hey  develop 
on  the  cornea,  jjcrforarion,  iritis,  and  su])puration  of  the 
globe  may  cause  destruction  of  the  eye. 

In  liemorrhagic  small-pox  hemorrhages  into  the  retina 
sometimes  occur,  causing  sudden  blindness. 

8ui)i)urative  otitis  may  occur  and  may  be  the  cause  of 
partial  or  complete  deafness. 

Pyjemia  is  a  very  rare  com])lication  of  variola,  although 
during  convalescence  superficial  cellulitis,  terminating  in 
abscess,  is  not  infrequent. 

In  severe  cases,  during  convalescence,  oedema  of  the  feet, 
due  to  anfumia,  is  frequently  met  with,  but  I  have  never  re- 
garded it  as  of  serious  import. 


LECTURE    XXVI. 


SCARLET   FEYER. 
Introduction.  —Morhld  Anatomy.— Etiology.— Symptoms. 

This  morning  we  come  to  the  study  of  the  second  in  the 
list  of  exanthematons  fevers,  namely,  scarlatina  or  scarlet 
fever.  This  name  has  been  given  on  account  of  the  bright 
red  appearance  of  its  eruption. 

Scarlet  feoer  is  an  inflammation  of  the  tegumentary  in- 
investment  of  the  entire  body,  both  cutaneous  and  mucous, 
accompanied  by  a  fever  of  an  infectious  or  contagious  char- 
acter. 

It  is  a  disease  of  childhood,  but  may  occur  at  any  age. 

Its  development  and  course  is  divided  into  periods : 
First,  the  period  of  invasion,  which  lasts  from  twenty -four 
to  forty-eight  hours ;  then,  the  period  of  eruption,  lasting 
from  five  to  seven  days  ;  afterwards,  the  period  of  desqua- 
mation, during  which  the  entire  epithelial  surface  is  re- 
moved. 

Some  authors  have  classified  this  disease  according  to  its 
severity  ;  others  according  to  the  prominent  organs  of  the 
body  which  are  involved  ;  others  according  to  the  promi- 
nent phenomena  which  attend  its  development. 

The  more  common  classification,  and  certainly  the  sim- 
plest, is  that  which  divides  it  into  scarlatina  simplex,  scar- 
latina anginosa,  and  scarlatina  rn,allgna.  I  shall  adopt 
tills  last  classification. 


Mni;i;ll)    ANA'I'oMV 


305 


Scarlet  IVv.'i- lias  many  dilV.'iviil  \y])>'<\  tlies.' aiv  as  uiilik.- 
as  some  of  tlif  (li-linci  l\i»"s  of  fi-vn-. 

]\[()Kini)  Anatomy.— Tlit'i-c  arc  no  oliaiacti'ristic-  anatonii- 
ral  lesions  of  tliis  (liscasc  cxcciit  tii()S(^  clianp'S  which  have 
tlifir  srat  in  iIk'  skin  am!  imicoiis  incinlirain'S.  I  stat(;d 
that  tilt'  characteristic  analoinical  chain;-. -s  of  variola  were 
tube  found  in  the  eruption  wliicii  followed  rc.L^nihir  stages 
of  development,  so  in  scarlet  fever  the  erupiion  is  lli.'  dis- 
tinu-nisliinii:  lesion. 

The  erui)tion  makes  its  ai>pearance  on  the  second  or  third 
day  after  the  commencement  of  the  febrile  symptoms. 

At  that  time  it  consists  of  very  numei-ons  and  closely 
arrgivgated  points  about  the  size  of  a  pin's  head  ;  between 
tiiese  the  skin  is  of  its  natural  color.  In  tyi)ical  cases, 
these  points  are  ecuially  distributed  over  the  entiiv  body 
except  the  face.  These  red  spots  are  usually  circular  in 
shape,  slightly  elevated  above  the  surrounding  skin,  and  so 
close  to  each  other  that  they  give  a  confluent  redness  to  the 
entire  surface.  In  mild  cases  the  red  points  remain  isolated, 
and  do  not  become  confluent ;  as  the  eruption  develops 
these  red  points  unite.  In  severe  cases  the  skin  becxMues 
turgid  and  swollen, and  presents  a  uniformly  red  and  glisten- 
ing ap})earance.  In  malignant  cases  the  hyperjemia  of  the 
skin  is  often  accompanied  by  more  or  less  exti^nsive  hemor- 
rhages, causing  pt^techiai  and  extensive  ecchymosis. 

The  eruption  gradually  increases  in  redness  to  a  certain 
point,  which  is  not  the  same  in  all  cases,  then  remains  un- 
changed for  twelve  or  twent^'-four  hours,  after  which  time 
the  redness  slowMy  passes  away.  Dining  the  course  of  the 
disease  the  color  often  changes  with  the  exacerbations  and 
remissions  of  the  fever.  As  a  rule,  the  degree  of  rt'dness 
depends  upon  the  int<'nsity  of  the  fever,  and  may  vary  from 
a  pale  red  to  a  dark  scarlet  color.  If  the  respiration  be- 
comes imjied'-d,  the  eruption  assumes  a  bluish-red  hue. 
During  the  first  forty-eight  hours  after  the  a]>i)earance  of 
the  eru])tion,  wIm-ii  the  respiration  is  nniinpeded,  the  red- 
ness completely  disapi)ears  under  firm  jjressure,  and  reap- 
p<}ars  as  soon  as  the  ])ressure  is  removed.  After  this  period, 
the  pressed  ])oint  do.-s  not  entirely  lose  its  red  color. 
20 


306  SCAKLET   FEVER. 

In  a  certain  proportion  of  cases,  the  eruption  only  ap- 
pears in  spots  on  tlie  surface  of  the  body,  on  the  trunk, 
or  face,  or  about  the  tlexors  of  the  Joints.  When  it  only 
appears  on  the  face  the  diagnosis  is  difficult.  In  addition 
to  the  cutaneous  hyperjemia  which  gives  the  redness  to  the 
surface,  there  is  more  or  less  serous  exudation  into  the 
"rete  Malpighii,"  which  is  followed  on  the  decline  of  the 
redness  of  the  surface  by  an  abundant  epidermic  exfolia- 
tion. This  exfoliation  marks  the  period  of  desquamation, 
which  may  immediately  follow  the  decline  of  the  redness 
or  it  may  be  delayed  a  few  days.  This  is  due  to  an  exces- 
sive production  of  newly-formed  epidermis,  and  the  process 
may  last  only  a  few  days,  or  if  the  eruption  is  abundant  it 
may  continue  for  several  weeks,  and  may  recur  a  second 
time  on  the  same  surface.  After  the  desquamation  has 
ceased,  it  does  not  reappear,  except  in  cases  of  relapse; 
these  are  followed  by  renewed  and  sometimes  by  a  very 
complete  desquamation. 

In  connection  with  these  cutaneous  changes  the  scarlatina 
poison  causes  changes  in  the  mucous  membrane  of  the 
mouth  and  throat,  the  most  frequent  of  which  is  catarrhal 
pharyngitis,  which  at  first  gives  to  the  mucous  surfaces  of 
the  tonsils  and  pharynx  a  red,  swollen,  and  dry  appear- 
ance. After  a  little  time,  these  mucous  surfaces  become 
covered  with  a  tenacious  mucus.  Upon  the  reddened  mu- 
cous membrane,  small  elevations  arise,  like  the  smaller 
follicles  in  an  ordinary  catarrh.  In  mild  cases,  all  these 
changes  disappear  in  a  few  days  ;  in  the  severer  cases,  the 
mucous  surface  assumes  a  dark,  livid  color,  the  parts  become 
more  or  less  oedematous,  and  are  covered  by  an  abundant 
secretion.  The  oedema  may  be  so  extensive  as  to  render 
deglutition  difficult  ;  often  the  tonsils  are  so  swollen  that 
they  touch  each  other.  Besides  the  redness  and  oedema  of 
the  mucous  membrane  of  the  mouth  and  throat,  there  is 
often  inflammation  of  the  parotid  and  sublingual  glands 
as  well  as  of  the  connective  tissue  of  the  neck.  This  gland- 
ular infltimmation  may  end  in  resolution,  but  often  it  termi- 
nates in  suppurative  or  diffused  necrosis.  It  may  give  rise 
to  extensive  gangrene  of  the  tonsils  and  adjacent  soft  parts ; 


MOIMUI)    ANATOMY,  30? 

somt'timi'3  it  is  followed  by  cxtt'iisive  abscesses  and  destruc- 
tion of  the  cellular  tissue  al)out  the  neck;  the  skin  in  the 
re«z;ion  may  slough,  and  not  infrequently  fatal  hemorrhage 
may  result  from  the  destruction  of  small  vessels. 

Diphtheria  is  so  often  a  complication  of  scarlatina  angi- 
nosa,  that  it  has  been  assume(l  that  there  is  some  necessary 
relation  b. 'tween  the  two  diseases.  Yet  diphtheria  is  as 
frequently  met  with  in  the  mildest  as  in  the  severest  types 
of  scarlatina,  and  occurs  in  every  stage  of  the  disease;  often 
it  is  present  during  the  period  of  incubation,  so  that  the 
symi^toms  of  the  two  diseases  appear  simultaneously. 
Again,  it  is  met  with  during  the  period  of  convalescence. 
In  some  instances,  scarlatina  seems  to  complicate  diph- 
theria. 

In  a  mild  form  of  scarlet  fever,  when  the  disease  runs  a 
regular  course,  the  nasal  mucous  membrane  is  usually  pale, 
and  its  secretion  is  not  increased.  When  the  disease  is 
severe,  the  nasal  mucous  membrane  becomes  secondarily, 
never  primarily,  involvtxl.  This  is  the  result  of  a  catarrhal 
affection  of  the  throat.  It  is  a  purulent  catarrh  of  the 
posterior  nares,  which  gradually  extends  to  the  anterior 
nares,  and  gives  rise  to  a  ver}^  troublesome  form  of  coryza. 

During  the  eruptive  period  of  scarlatina,  affections  of  the 
ear  frequently  occur  in  connection  with  those  of  the  throat. 
Usually  these  have  their  seat  in  the  middle  ear.  They  are 
alwavs  tedious  and  may  become  chronic. 

Next  to  the  skin  and  mucous  surfaces,  the  kidneys  are 
the  organs  most  frequently  affected  in  this  disease.  There 
is  no  question  but  that,  in  a  certain  proportion  of  cases,  re- 
covery takes  place  without  any  kidney  lesions;  but  these 
are  the  exceptions  and  not  the  rule.  The  usual,  and  by  far 
the  mildest  affection  of  the  kidneys  in  scarlatina  is  a  ca- 
tarrh of  the  uriniferous  tubules  marked  by  a  more  or  less 
extensive  epith<'lial  desquamation.  In  some  epidemics  the 
scarlatina  poison  induces  croupous  intiammation  of  the 
uriniferous  tubules  instead  of  simjjle  catarrh. 

The  tubules  of  the  cortical  substance  of  the  kidneys  are 
most  extensively  affected  ;  the  morbid  processes  commencing 
at  the  Malpighian  tufts  follow  the  course  of  the  convoluted 


308  SCAELET  FEVER. 

tubules.     If  the  tubules  are  only  slightly  affected  there 
will  be  no  symptoms  except  a  slight  albuminuria. 

In  Avell-markiHl  scarlatinal  nephritis,  the  epithelial  cells  of 
th(;  uriniferous  tubes  will  be  found  clouded,  enlarged,  and 
changed  in  shape  and  position,  and  frequently  entirely 
destroyed,  or  they  may  entirely  block  up  the  tubules. 
Circumscribed  inflammatory  masses  will  be  found  scattered 
throughout  the  substance  of  the  kidneys  ;  these  cause  the 
kidneys  to  present  the  appearance  of  interstitial  nephritis. 
Sometimes  abscesses  form  in  the  kidneys.  These  kidney 
changes  are  rarel}'  well  marked  before  the  second  or  third 
week  of  the  disease,  and  usually  terminate  in  complete 
recovery  ;  they  very  rarely  lead  to  chronic  kidney  disease. 

The  character  and  extent  of  these  kidney  changes  varies 
in  different  epidemics.  During  some  epidemics,  the  kidney 
changes  are  slight ;  during  other  epidemics  almost  every 
case,  whether  mild  or  severe,  will  be  attended  by  extensive 
kidney  lesions. 

At  the  post-mortem  examination  of  scarlet  fever  patients, 
you  will  always  find  more  or  less  extensive  congestion  of 
the  internal  organs,  such  as  congestion  of  the  brain,  liver, 
spleen,  etc.,  but  these  congestions  do  not  vary  in  character 
from  those  met  with  in  other  acute  infectious  diseases.  It 
has  been  said  that  the  visceral  lesions  of  this  disease  do  not 
essentially  differ  from  those  of  typhus  fever,  that  there  is 
the  same  tendency  to  softening  of  the  spleen  and  liver,  and 
that  the  condition  of  the  cerebral  vessels  in  the  two  diseases 
is  very  similar.  In  both,  the  changes  in  the  constituents 
of  the  blood  are  such  as  to  diminish  its  coagulating  power  ; 
in  both,  the  mucous  membrane  of  the  stomach  and  intestines 
undergoes  similar  changes,  the  Peyerian  patches  will  often 
be  found  presenting  the  "  shaven-beard  appearance." 

When  scarlet  fever  poison,  which  usually  only  induces 
changes  in  the  skin,  throat,  and  kidneys,  excites  inflam- 
mation in  the  joints,  pleura,  and  pericardium,  these  latter 
must  be  regarded  as  complications ;  they  do  not  belong  to 
the  regular  history  of  the  disease. 

Etiology. — The  cause  of  scarlet  fever  is  a  peculiar  sub- 
stance which  is  transferable  from  the  sick  to  the  healthy. 


Scarlet  fever  is  unquestionably  a  eonta.^ions  disoaso.  It,  lias 
been  claimed  by  some  that  it  is  only  pro])a,<;ated  by  con- 
tagion ;  by  others  that  sporadic  cases  do  occasionally  occur; 
but  there  is  little  doubt,  if  the  history  of  every  cast;  of  sup- 
])()sed  sj>ontaneous  scarlet  fever  could  be  carefull}'  taken,  it 
would  be  found  that  at  no  jilace  and  at  no  limr  had  th.-re 
ever  oi'currcd  a  case  of  si)ontancous  oriuin. 

Tilt'  disease  may  be  conveyed  directly  fit)m  llif  alffctctl  to 
the  hcaltliy  by  contact.  It  may  also  be  conveyed  for  a  fi^w 
feet  throuich  the  atnit)si)h.'rt%  and  also  by  clotliin<,^  wliich 
has  been  thoroughly  saturated  with  the  scarlet  fever  poist)n  ; 
therefore  it  may  be  considered  a  portable  disease. 

Animals  that  have  been  around  those  sick  with  scarlet 
fever  may  convey  it.  I  now  recall  one  instance  in  which 
the  scarlet  fever  poison  was  conveyed  in  this  way.  For  a 
number  of  days  a  little  poodle  dog  had  been  around  childrt>ii 
sick  with  scarlet  fever,  and  in  a  single  visit  to  the  children 
of  another  family  the  disease  was  conveyed. 

There  has  been  considerable  discussion  as  to  whether  the 
disease  can  or  cannot  be  conveyed  in  milk.  I  do  not  say 
that  this  is  impossible,  but  I  do  not  think  it  probable  that 
it  is  so  conveyed. 

The  infection  of  scarlatina  is  not  so  certain  as  that  of 
measles  or  small-pox.  When  one  member  of  a  family  is 
sick  with  measles,  usually  every  other  member  of  that 
family  who  has  not  had  measles  will  contract  the  disease  ; 
whereas,  one  member  of  a  family  may  be  sick  with  scarlet 
fever  and  evt^ry  other  member  may  escajie. 

I  stated  that  some  ])ersons  seem  to  have  a  certain  idiosyn- 
crasy, so  that  when  they  are  bnnight  in  contact  with  the 
typhus  fever  poison  they  do  not  contract  the  disease;  so 
certain  persons  may  be  brought  in  contact  with  the  poison 
of  scarlet  fever  and  yet  not  contract  the  disease.  The 
poison  which  they  receive  into  the  system  has  power  to  pro- 
duce some  of  the  symptoms,  but  has  nt)t  i)ower  to  fully 
develop  the  disease. 

Scarlet  fever  can  be  coniniunicateil  fit)iu  t.ne  intliviilual  to 
anothiM- by  inoculatitm.  If  you  take  st)me  t>f  the  watery 
material  or  serum   that  can  be  obtained  from  the  minute 


310  SCARLET   FEVER. 

vesicles  occasionally  seen  upon  the  surface  of  the  body  in 
connection  witli  the  scarlet  fever  erniDtion,  and  introduce  it 
into  the  body  of  an  individual  who  has  not  had  scarlet  fever, 
it  will  develop  the  disease.  It  has  been  proposed  to  inoculate 
persons  who  have  not  had  scarlet  fever  in  the  same  manner 
as  one  would  inoculate  persons  who  have  not  had  small- 
pox, and,  by  so  doing,  produce  a  modification  of  the  disease. 
But  it  has  been  found  by  experiment  that  those  who  have 
been  inoculated  for  scarlet  fever  have  suffered  more  severely 
than  those  who  contracted  the  disease  by  any  of  the  com- 
mon methods  of  contagion. 

There  is  no  question  but  that  the  scarlet  fever  poison  ca,n 
also  be  introduced  into  the  system  through  the  respired  air, 
but  whether  it  can  be  taken  into  the  system  through  the 
medium  of  food  or  fluids  is  still  an  unsettled  question. 

We  are  now  brought  to  a  question  of  great  practical 
imj)ortance.  If  tlie  disease  can  be  conveyed  by  clothing,  is 
it  safe  for  a  physician  to  visit  patients  sick  with  scarlet 
fever,  and  go  from  them  directly  to  those  who  have  not  had 
the  disease  ?  Unquestionably,  it  is  possible  to  so  conve}^  the 
disease,  but  in  my  own  experience  I  know  of  no  case  where 
it  has  been  so  conveyed. 

The  clothing,  in  order  to  be  sufficiently  impregnated  with 
the  poison  to  render  it  a  means  of  contagion,  must  be  longer 
exposed  than  is  the  case  when  a  physician  makes  a  visit  of 
ordinary  length. 

I  do  not  hesitate  to  go  directly  from  a  patient  who  has 
had  scarlet  fever  to  one  who  has  never  had  the  disease. 

While  making  my  daily  round  of  visits  on  scarlatina 
patients,  I  have  frequently  taken  my  own  child,  who  lias 
never  had  the  disease,  to  ride  with  me,  without  fear  of 
conveying  to  her  the  disease. 

Unquestionably,  nurses  who  have  been  with  a  scarlet 
fever  patient  for  a  number  of  days,  and  whose  clothing  has 
become  filled  with  the  poison,  may  carry  the  disease.  Such 
persons  should  change  their  clothing  before  they  go  from 
the  sick  to  the  healthy. 

With  regard  to  the  real  nature  of  the  scarlatina  poison, 
the  oft-repeated  question  comes  to  us,  Is  it  a  living  organ- 


SYMPTOMS.  311 

ism  or  :ni  impalpahle>  poison  '.  It  is  ininecessary  to  repeat 
wliai  has  hrcii  already  said  u])on  this  })()iiit.  Thr  saiiio 
ar^iuuciits  iiuld  _ii;()od  in  rr-rai-d  to  this  fever  as  in  regard  to 
the  other  levers  which  we  ha\e  been  coiisich'riiii^. 

Tlie  period  at  wliicii  tiiis  disease  is  most  infectious  is 
])rol)al)ly  the  desquamative  }>eriod,  altliougli  some  maintain 
that  it  is  most  infeetious  during  the  eruptive  period.  An 
individual  is  almost  certain  never  to  liave  a  second  attack. 

The  i)eriod  of  incubation  varies  from  two  to  ten  days,  the 
average  duration  being  from  four  to  seven. 

Age  has  a  great  influence  on  individual  predisposition. 
Tlie  greatest  susceptibility  to  the  influence  of  the  poison 
exists  between  the  second  and  seventh  years ;  it  rapidly 
diminishes  after  the  ninth  year,  so  that  adults,  and  esj)e- 
cially  the  aged,  have  only  a  slight  predisposition  to  the 
infection. 

Scarlet  fever  may  be  endemic  or  epidemic.  No  reason 
can  be  assigned  for  the  variations  in  type  or  severity  of  this 
disease.  For  years  the  type  of  fever  which  appears  in  a 
given  locality  will  be  exceedingly  mild  in  character,  and 
the  cases  will  be  mostly  sporadic,  when  suddenly,  without 
any  assignable  cause,  a  most  malignant  epidemic  of  the 
disease  will  prevail.  Usually  epidemics  of  scarlatina  pre- 
vail in  the  autumn  and  spring. 

Symptoms. — The  symi>toms  of  scarlet  fever  vary  with  the 
type  and  with  the  severity  of  the  fever.  In  moderately 
severe  cases,  before  the  ap]>earance  of  the  eru])tion,  the 
patient  will  have  more  or  less  sevei'e  headache,  pain  in  the 
back  and  limbs,  and  at  lirst  coldness  of  the  surface.  In 
some  cases  rigor-;  will  occur,  and  i)erha])S  distinct  chills. 
In  children  convulsions  often  occur.  These  ushering-in 
symptoms  are  immediately  followed  by  a  sensation  of  in- 
tense heat,  with  great  acceleration  of  the  jjulse,  which  at 
this  time  often  beats  120  or  i;}()  per  minute.  Tliere  will  also 
be  nausea  and  vomiting,  whicli  symptoms  are  frequently  the 
most  ])ersistent  and  distressing.  Besides,  there  will  be  a 
rapid  rise  in  temju'ratuie.  Ir  may  reach  l(>:r  F.  or  1(»4  F., 
within  a  few  houi-s.  Wit hin  a  jieriod  lastin^•  fmni  twelve 
to  forty-eight    hours,   th''  average  about    lhin\-six  hours, 


312  SCARLET  FEVEE. 

the  eruption  makes  its  appearance,  and  the  fever  increases. 
The  elevation  in  temperature  is  accompanied  by  restless- 
ness, a  burning  sensation,  perhaps  delirium  ;  the  nausea 
and  vomiting  become  more  urgent,  and  now  the  papillae  of 
the  tongue  become  swollen,  and  the  organ  presents  the 
appearance  of  a  strawberry.  It  has  been  called  the  "  straw- 
berry tongue"  of  scarlet  fever.  This  appearance  is  not 
commonly  seen  in  the  milder  cases,  but,  as  a  rule,  is  present 
in  all  the  severer  cases.  With  the  appearance  of  the  erup- 
tion, all  the  symptoms,  perhaps  excepting  the  pain  in  the 
head,  increase  in  severity.  The  urine,  if  it  has  been  scanty, 
will  now  become  more  so,  and  may  be  nearly  suppressed  ; 
if  it  has  been  sufficiently  abundant,  not  unfrequently,  as 
the  eruption  makes  its  appearance,  the  urine  becomes 
scanty  and  high-colored. 

In  some  cases  the  disease  is  so  mild  that  there  is  but 
little  disturbance,  except  that  caused  by  the  eruption.  In 
other  cases  the  disease  is  ushered  in  by  violent  nervous 
symptoms,  such  as  delirium  and  coma,  accompanied  by 
extreme  exhaustion,  and  the  patient  dies  before  the  erup- 
tion makes  its  appearance.  In  other  words,  the  patient 
dies  during  the  period  of  invasion,  from  the  overwhelming 
of  the  nervous  system  with  the  scarlet  fever  poison. 

During  the  earlier  stages  of  the  disease  the  throat  symp- 
toms are  quite  characteristic.  Adults  and  older  children 
complain  of  a  pricking  sensation  in  the  throat,  and  difficulty 
in  deglutition  ;  the  tonsils,  uvula,  and  posterior  wall  of  the 
pharynx  are  red  and  (Edematous,  and  from  their  appear- 
ance with  the  attendant  symptoms,  in  most  instances,  you 
are  very  early  able  to  decide  that  the  case  is  one  of  com- 
mencing scarlatina.  There  are  cases  in  which  the  throat 
symptoms  are  altogether  absent  at  first,  and  do  not  come 
on  until  later  in  the  disease. 

We  will  now  study  in  detail  the  symptoms  which  mark 
the  development  of  this  disease. 

As  I  have  already  stated,  the  whole  course  of  scarlet 
fever  may  conveniently  be  divided  into  three  stages. 

First,,  the  stage  of  invasion,  or  the  febrile  stage. 

Second^  the  stage  of  eruption. 


SYMPTOMS.  ''i\'S 

Tliird,  the  stage  of  desqiuinuition. 

The  duration  of  tlie  stage  of  invasion  varies  in  diirtTt-nt 
cases  according  to  the  type  of  the  disease.  In  most  cases, 
it  is  from  twelve  to  twenty-four  hours ;  it  may  be  four  or 
live  days.  Usually  the  onset  is  marked  by  chilliness  and 
slight  rigor,  foUowed  by  a  rapid  rise  in  temperature.  The 
skin  becomes  dry,  the  face  Hushed,  and  the  pulse  accelera- 
ted. At  the  same  time  there  is  slight  soreness  of  tin*  throat, 
the  face  appears  red  and  dry,  the  neck  is  stiif,  and  there  is 
some  tenderness  about  the  joints.  Vomiting  and  thirst  are 
prominent  symi)tonis.  The  tongue  is  red  at  its  tip  and 
edges,  the  papilhe  are  enlargt'd,  ;ind  it  presents  the  so-called 
strawberry  appearance.  Lassitude,  pain  in  the  head,  aching 
of  the  limbs  and  restlessness  are  generally  present.  There 
may  be  some  delirium  at  night. 

Twenty-four  hours  after  the  commencement  of  the  fever 
of  invasion,  an  erujjtion  makes  its  appeanince,  when  the 
period  of  invasion  is  completed.  The  period  of  iiuuibation, 
or  the  time  which  elapses  between  the  exposure  and  the  ap- 
pearance of  the  eruption,  varies.  By  some  the  erui)tion  is 
said  to  appear  as  early  as  twenty-four  hours  after  exposure, 
while  others  claim  that  one  or  two  weeks  may  elapse  after 
the  exposure  before  the  disease  is  developed,  that  the 
average  time  is  six  or  seven  days.  You  can  make  no  defi- 
nite statement  in  regard  to  the  duration  of  the  period  be- 
tween the  exposure  and  the  appearance  of  the  eruption. 

The  eruption  first  makes  its  appi?arance  upon  the  neck 
and  upi)er  portion  of  the  chest,  and  is  first  seen  as  little 
red  dots,  varying  in  size  from  a  line  to  a  line  and  a  lialf  in 
diameter.  These  gradually  coalesce  and  the  erui)lion  ex- 
tends over  the  entire  surface  of  the  body,  perhaps  on  tlie 
face,  and  lastly,  it  appears  on  the  lower  extremiti»'S.  It 
])resents  its  iMightest  apjiearance  upon  the  evening  of  the 
fourth  day. 

On  the  morning  of  the  fourth  day,  if  you  draw  your 
fimrer  across  the  surface,  a  clear,  well-defined  lin.'  will  be 
in:id«',  wliich  will  remain  for  some  time.  The  distinct  white 
line  which  follows  the  finger  is  a  point  of  some  imi)ortance 
in  distinguishing  scarlet  fever  fr.tin  roseola,  a  disease  which 


314  SCARLET    FEVER. 

lias  an  eruption  closely  resembling  tliat  of  scarlet  fever.  In 
roseola,  the  well-defined  white  line  produced  by  drawing 
the  finger  across  the  surface  will  be  almost  instantly  dis- 
placed by  the  returning  redness.  It  does  not  remain  dis- 
tinct as  in  scarlatina.  The  eruption  remains  visible  six  or 
seven  days.  Usually,  it  begins  to  fade  upon  the  fourth  day, 
and  by  the  sixth  day  it  has  entirely  disappeared,  and  des- 
quamation has  commenced.  The  period  of  desquamation 
lasts  about  two  weeks,  during  which  time  there  is  the  great- 
est danger  of  communicating  the  disease.  At  the  end  of 
that  period,  if  no  complication  occurs,  the  j^atient  is  well. 
The  fine  scales  which  are  so  abundantly  thrown  ofi:  contain 
the  specific  poison,  and  they  are  so  delicate  that  they  are 
blown  about  with  every  breath,  and  carried  in  every  current 
of  air,  and  are  in  the  most  favorable  condition  to  be  taken 
into  the  system  in  the  respired  air. 

Some  have  maintained  that  the  contagious  period  in  this 
disease  does  not  occur  until  the  period  of  desquamation. 
This  statement  is  not  sustained  by  clinical  facts.  The 
amount  of  the  desquamation  depends  upon  the  intensity  of 
the  eruption.  The  skin  has  a  dry  feel  before  desquamation 
commences.  Where  the  skin  is  thin,  the  epidermis  comes 
off  in  thin  scales.  Where  the  skin  is  thick,  as  on  the  palms 
of  the  hands  and  soles  of  the  feet,  it  peels  off  in  extensive 
patches.  With  the  desquamation,  the  fever  subsides  more 
or  less  rapidly. 


lectuim:  XXVII. 


SCARLET  FEVER. 
Si/mptoms  {continued).— Coviplications.—ScquelcE. 

I  WILL  briefly  repeat  some  things  said  at  my  last  lecture 
in  n*iVr(>nce  to  the  phenomena  which  attend  tlie  develop- 
ment of  scarlet  fever.  Its  symptoms  may  be  divided  into 
three  stages  :  a  stage  of  invasion,  a  stage  of  eruption,  and  a 
stage  of  descpiamation.  After  a  variable  length  of  time 
from  the  exposure,  var}ing  from  two  to  six  days,  the  re- 
cipient of  the  bcarlet  fever  poison  begins  to  have  chilly  sen- 
sations, alternating  with  flashes  of  heat,  rarely  a  distinct 
chill.  Following  this  there  is  some  soreness  of  the  throat, 
headache,  pain  in  the  back  and  limbs :  and  the  temperature 
rapidly  rises,  often  in  twelve  liours  reaching  104^  F.  With 
this  rise  in  temperature  there  is  an  acceleration  of  the  pulse, 
and  not  unfrequently  very  young  children  will  l)e  seized 
with  convulsions,  rapidly  pass  into  a  state  of  coma,  and  re- 
main unconscious  until  the  })eriod  of  eruption.  Aftt.'r  the 
period  of  invasion  has  continued  two  or  three  days,  a  rash 
will  appear,  flrst  upon  the*  neck  and  chest ;  gradually  it 
extends  over  the  face  and  trunk,  then  is  seen  upon  the  ex- 
tremities. This  rash  flrst  apj)ears  as  flne  red  dots  ;  these 
dots  form  patches,  wliich  quickly  coalesce. 

After  the  second  day  of  the  eruption,  if  not  before,  the 
entire  surface  will  present  an  uniform  redness,  the  color  va- 
rying with  the  severity  of  the  disease.  In  the  milder  eases 
you  will  have  a  bright  rose-vd  eruption  or  rash,  while  ia 


316  SCARLET    FEVER. 

the  severer  types  the  eruption  will  assume  an  appearance 
resembling  the  deep-red  color  of  the  boiled  lobster.  The 
darker  the  eruption,  the  more  severe  the  form  of  the  dis- 
ease and  the  greater  the  danger.  When  the  eruption  is 
fully  developed  you  will  notice  that  the  surface  is  some- 
what elevated,  the  parts  present  a  swollen  appearance,  the 
vessels  of  the  skin  seem  to  be  congested,  and  there  will  be 
soreness  of  the  throat  more  marked  than  in  the  febrile 
stage.  Usually,  vomiting  is  present  at  the  commencement 
of  the  disease,  but  becomes  more  severe  and  a  more  marked 
symptom  as  the  stage  of  eruption  is  ushered  in  ;  if  not  i^res- 
ent  at  the  commencement  it  is  certain  to  make  its  appear- 
ance with  the  appearance  of  the  eruption.  The  vomiting  is 
peculiar,  not  on  account  of  the  matters  ejected,  but  the  act 
of  vomiting  is  projectile  in  character.  In  scarlatina  the  con- 
dition of  the  throat  depends  upon  the  severity  of  the  dis- 
ease. In  some  cases  there  is  simpl}^  a  blush  of  redness  over 
the  posterior  portion  of  the  pharynx  and  uvula  and  ante- 
rior pillars  of  the  soft  palate.  In  other  cases  you  will  no- 
tice a  general  tumefaction  of  all  the  soft  parts  of  the  throat 
which  can  be  seen,  and  the  tonsils  will  be  the  seat  of  a  more 
or  less  intense  parenchymatous  inflammation,  which  gives 
rise  to  a  swelling  that  encroaches  more  or  less  upon  the 
pharynx.  Again,  you  will  have  ulcerative  pharyngitis,  as 
it  is  termed,  or  upon  the  surface  of  the  enlarged  tonsils  and 
swollen  mucous  membrane  of  the  phar3^nx  you  may  have 
an  exudation,  which  hereafter  will  be  more  fully  described. 

In  the  ordinary  form  of  scarlatina,  such  as  I  am  now  de- 
scribing, when  it  runs  its  regular  course  you  will  not  have 
much  swelling  of  the  glands  about  the  neck,  nor  very  much 
tumefaction  of  the  soft  tissue  in  the  pharynx. 

The  eruption  will  reach  the  maximum  of  development 
upon  the  fourth  day,  and  will  remain  visible  six  days. 
Generally  during  this  time  the  temperature  continues  to 
rise  until  perhaps  it  has  reached  106°  F.  or  107°  F.  In  the 
meantime  the  pulse  may  increase  to  120,  or  even  140,  or  per- 
haps 150  beats  per  minute,  and  not  unfrequently  there  is 
some  delirium  during  this  stage ;  there  may  be  also  more  or 
less  stupor.     There  is  an  intense  itching  and  burning  upon 


iRREor  I.  A  urn  Ks.  317 

the  surface,  and  an  intense  restlessness  depend iniz;  \\\)(m  tlu- 
congestion  of  tln'  cutaneous  covering;  of  the  hody. 

Lpon  the  ei^dith  day  of  the  eiu])tion  you  will  notice  that 
the  temperature  begins  to  decline,  and  at  the  same  time  it 
can  be  seen  that  the  eruption  has  fach'd  in  a  marked  degree 
over  the  juirts  wIi.mv  it  first  made  its  a])pearance,  especially 
about  the  neck.  This  fading  of  the  eruption  goes  on  ra])- 
idly,  so  that  by  the  end  of  the  eighth,  certainly  early  on  the 
ninth  day,  sometimes  as  early  as  the  sixth  day,  there  is  no 
longer  any  eru])tion  visible  on  the  surface  of  the  body. 

With  the  disai»i>earance  of  the  rash,  desquamation  com- 
mences, and  with  this  there  will  be  a  still  more  marked 
fall  in  temperature  and  diminished  frequency  of  the  pulse. 
All  the  febrile  symptoms  disappear,  all  the  throat  symptoms 
subside,  there  is  no  longer  any  difficulty  in  deglutition, 
there  is  no  more  pain  in  the  throat,  no  more  swelling 
of  the  external  glands,  if  previously  it  had  existed.  The 
desquamation  continues  for  from  lifteen  to  sixteen  days, 
after  which  time  the  patient  is  in  a  state  of  convalescence. 

The  entire  period  occupied  by  a  case  of  scarlet  fever  when 
it  runs  its  regular  course  is  from  two  to  three  weeks. 

Having  given  you  a  description  of  the  development  of  an 
ordinary  case  of  scarlet  fever,  I  must  state  to  you  that  this 
disease  is  liable  to  irregidartties  in  its  develoimient  and 
course,  and  to  these  it  is  important  that  I  should  direct 
your  attention. 

It  is  claimed  by  some  that  these  irregularitii's  (h']M'iid 
upon  the  organ  or  set  of  organs  primarily  afTected  by  tli<' 
scarlet  fever  poison.  They  are  rather  due  to  some  ix'culi- 
arity  in  the  type  of  the  disease,  to  the  degree  of  poisoning, 
and  in  some  instances  to  the  particular  set  of  organs  that 
are  involved  in  the  different  epidemirs. 

In  some  epidemics  you  will  see  even  mildrr  Coiins  of  the 
disease  than  I  have  yet  described.  The  atta<k  may  be  so 
mild,  and  there  may  be  so  little  fever,  that  if  the  .•ru])tion 
■was  not  present,  you  would  not  be  able  to  recognize  the 
scarlet  fever ;  and  even  that  may  be  so  slight  that  the  stage 
of  eruption  and  the  stage  of  desquamation  may  pass  un- 
noticed, and  you  may  find  yourself  scarcely  able  to  decide 


318  SCARLET   FEVER. 

whether  the  patient  lias,  or  has  not,  had  an  attack  of  scarlet 
fever 

The  most  frequent  irregularity  in  the  manifestation  of 
tlie  disease  is  noticed  in  that  class  of  cases  where  we  liave 
complications  resulting  from  the  overwhelming  of  tlie 
cerebro-spinal  system  with  the  scarlatina  poison.  This  is 
due  to  some  peculiarity  of  the  poison,  and  is  characteristic 
of  certain  epidemics. 

In  a  large  number  of  cases  in  the  febrile  stage,  especially 
in  young  children,  convulsions  may  occur,  but  they  do  not 
depend  upon  the  peculiarity  to  which  I  refer. 

In  the  class  of  cases  to  which  reference  has  been  made, 
where  complications  arise  from  the  overwhelming  of  the 
cerebro-spinal  system  with  the  scarlatina  poison,  from  the 
very  onset  of  the  disease  there  seems  to  be  a  tendency  to 
stupor  and  delirium,  a  peculiar  restlessness,  an  apparent 
wandering,  a  picking  at  the  bed-clothes,  accompanied  by  a 
peculiarity  in  the  appearance  of  the  eruption,  which  may 
cause  it  to  assume  the  boiled-lobster  appearance,  or  even  a 
darker  hue.  The  eruption  is  slow  in  its  development,  and 
there  is  not  that  uniform  redness  over  the  entire  body  that 
is  seen  in  ordinary  cases  ;  it  appears  in  patches,  and  with  it 
there  is  exhibited  a  tendency  to  blueness  of  the  finger-ends, 
indicating  that  there  is  acting  upon  the  nervous  sj'stem  a 
poison  which  possesses  the  power  of  very  greatly  lowering 
the  vitality  of  the  patient. 

There  is  a  class  of  cases  in  which  there  is  not  much  swell- 
ing of  the  throat,  nor  is  the  pulse  more  frequent  than  130 
or  140  per  minute,  but  during  the  second  day  of  the  erup- 
tion the  temperature  ranges  very  high,  reaching  107°  F.,  or 
108°  F.  Under  such  circumstances  the  disturbance  of  the 
nervous  system  is  due  to  the  high  temperature  which  may 
have  been  present  for  two  or  three  days  ;  these  disturbances 
may  be  prevented  if  the  temperature  is  not  allowed  to  rise 
above  103°  F.  or  104°  F. 

Again,  in  cases  where  there  is  marked  swelling  of  the 
throat,  and  a  general  infiltration  of  the  tissues  and  glands 
of  the  neck,  the  development  of  the  nervous  phenomena  is 
due  to  an  interference  with  the   return  circulation.      The 


IRREOULAKITIKS.  HIO 

condition  which  ^ives  rise  to  the  cerebral  symptoms  is  one 
of  nit'chaiiical  ciTi'hral  confrcstion,  if  T  may  use  tlic  term  in 
this  connection. 

There  is  still  another  class  of  cases  in  which  tlif  marked 
nervons  plienomtMia  appear  still  later  in  tiif  ])roirrt'ss  of  the 
disease.  Liuh'r  sn<-li  circumstanct's  rlicy  often  indicate  a 
typhoid  condition.  This  tvjdioid  condition  is  not  iiidiicrd 
nor  ai-e  th<^  ntM'voiis  ])ln'nonu'na  dcvdojx'd  on  account  of  tiie 
]>eculiar  elVect  ])roduc»'(l  H])on  the  nerve  centres  by  the  scar- 
let fever  poison,  nor  are  they  due  to  the  effects  produced  by 
a  liiuli  tem])erature,  nor  by  an  interferenct^  with  the  return 
circulation,  but  they  are  due  to  septic  poisoning,  a  poison- 
ing entirely  different  from  scarlet  fever  poisoning.  The  ner- 
vous phenomena  develop  after  tlie  eru])tion.  Durintr  the 
develoi)ing  period,  you  may  have  noticed  a  peculiar  icho- 
rous discharge  from  the  nostrils,  and  frequently  you  hear 
it  said  that  the  patient  has  become  repoison«>d  by  scarlet 
fever  poison,  but  this  is  not  the  case  ;  he  has  become  re- 
poisoned  by  the  septic  element  of  these  discharges. 

During  the  period  of  desquamation  you.  may  have  the 
nervous  S3'stem  involved,  in  consequence  of  the  presence  of 
unemic  poisoning. 

The  mere  terms,  scarlatina  simplex,  scarlatina  anginosa, 
and  scarlatina  maligna,  do  not  indicate  all  that  may  be 
included  under  each  division.  You  must  remember  that 
scarlatina  maligna  is  that  form  of  the  disease  in  which  tiie 
cerebro-spinal  sj'stem  becomes  early  involved,  in  conse- 
quence of  some  peculiarity  of  the  scarlet  fever  poison  ;  or  it 
becomes  involved  while  the  eru])tion  is  being  developed, 
and  depends  upon  high  temperature  ;  or  it  becomes  in- 
volved in  connection  with  extreme  swelling  of  the  tissue  of 
the  neck,  giving  rise  to  interference  of  the  return  cerebral 
circulation,  or  in  consequence  of  a  septic  or  unemic  ele- 
ment. What  the  changes  are  that  ])roduce  these  nervous 
phenomena,  when  high  temperature  is  present,  is  still  an 
unsettled  (Question. 

Again,  scarlet  fever  may  run  an  irreLriilar  <'ourse  in  those 
cases  in  which  there  is  jnesenf  an  extensive  inliltiation  of 
the  tissue  of  the  neck,  with  inllatnmatory  i)roducts.  swell- 


320  SCAELET    FEVER. 

ing  of  the  glands,  and  extensive  suppuration.  Not  infre- 
quently these  cases  terminate  fatally;  doubtless  in  some 
cases  the  extensive  suppuration  in  the  areolar  tissue  about 
the  neck  produces  this  result,  and  in  other  cases  it  is  pro- 
duced by  the  interference  with  respiration  caused  by  en- 
largement of  the  gland  and  swelling  of  the  tissues  of  the 
neck.  In  these  cases  there  is  a  certain  amount  of  danger 
from  oedema  glottidis,  the  consequence  of  extension  of  the 
inflammation  from  the  adjacent  tissues. 

There  are  cases  in  which  the  eruption  is  not  very  well 
marked  ;  the  patient  passes  safely  through  the  stage  of 
eruption,  and  the  stage  of  desquamation  is  fully  estab- 
lished ;  but,  instead  of  making  a  good  recover}^  from  this 
point,  immense  abscesses  are  raj)idly  developed  in  the  cervi- 
cal region,  blood-changes  begin  to  manifest  themselves — 
such  changes  as  allow  of  the  occurrence  of  hemorrhages — 
and  the  patient  passes  into  a  typhoid  condition,  with  hem- 
orrhages occurring  from  the  nose,  mouth,  intestines,  etc., 
and  death  ensues.  Such  a  result  is  produced  by  the 
peculiar  action  of  the  septic  poison  developed  during  the 
suppurative  process. 

I  have  already  referred  to  a  scarlatinal  coryza,  in  which 
the  discharge  contains  elements  capable  of  producing  septic 
poisoning.  I  have  come  to  regard  this  coryza  as  an  unfa- 
vorable symptom.  The  clear  serum  which  runs  over  the 
lip  never  causes  death  ;  but  the  fact  that  it  sometimes  pro- 
duces excoriation  and  ulceration  of  the  tissues  with  which 
it  comes  in  contact,  indicates  that  there  are  nasal  and 
pharyngeal  changes  which  may  destroy  life  ;  especially  is 
this  the  case  in  young  children. 

Sloughing  ulcers  sometimes  develop  in  the  mouth  and 
throat ;  and,  when  they  do  occur,  the  patient  is  said  to 
have  ulcerative  stomatitis  ;  but  these  ulcerations  are  really 
due  to  a  peculiarity  of  the  scarlatina  poison.  Under  such 
circumstances,  your  patient  may  go  on  through  the  period 
of  eruption,  enter  the  stage  of  desquamation,  and  then 
rapidly  sink  and  die,  with  symptoms  similar  to  those 
which  attend  diphtheria.  Although  the  odor  of  the  breath 
may  very  closely  resemble  that  noticed  in  some  cases  of  diph- 


SEQUKL.E.  '.V2l 

tlit'iia,  tlifiT  is  no  (li|ililliiTitic  I'Midaiion  present.  Wln-ii 
diphtlit'iia  docs  occur,  it  is  (Irvch^iifd  as  ii  coinijlicatioii  or 
siHiiit'la  ;  it  (Iocs  not  Ix'loiiii;  to  the'  I't-gular  liistoiy  of  scarhi- 
tina,  and  is  an  ••nlir»'l\"  ditVfi-<-nl  disease,  dcjx'ndiiiL;-  ujtoii 
an  cntin-iy  dilVcicnt  poison,  wJiich  makes  its  upjx-aiance 
alter  the  scarlet  fever  ])oison  lias  s])ent  itsell*.  Reniend)er 
that  scailalina  and  di)>hiheria  are  distinct  dis(:'ases,  and 
cannot  he  develo})ed  the  one  from  tiieotiier,  and  tliat  the 
condition  I  have  l)een  descrihiiii;-,  whicii  resembles  di])lit]ie- 
ria,  is  siin])ly  a  scarlatinal  coryza  which  indicates  the  exist- 
ence of  slou,!j;hini;  phar3ii,i^itis. 

Scarlatina  ma}' also  be  miide  to  run  an  irregular  course 
by  the  development  of  intlammation  of  the  internal  eai*. 
This  intlammation  extends  from  the  throat  ii])  the  Kusla- 
cliian  tube,  involves  the  middle  ear,  and  gives  ris(^  to  a  train 
of  symptoms,  such  as  intense  pain,  delirium,  and  rolling  of 
the  head,  all  of  which  suggest  the  ])resence  of  acute  meningi- 
tis. I  recall  several  instances  in  whicli  the  diagnosis  of 
acute  meningitis  was  made,  where  from  the  after  history  of 
the  case  there  was  no  question  but  that  the  symptoms  were 
due  to  such  an  intlammation  of  the  middle  and  internal  ear. 
AVhen  such  an  intlammation  occurs,  you  should  be  prepared 
to  relieve  3"our  patient.  The  method  of  ])rocedure  for  the 
relief  of  this  condition  you  will  learn  from  lectures  in  an- 
other department  of  medicine. 

All  these  dilTering  conditions  I  have  been  describing  are 
usually  spoken  of  as  complications  of  scarlet  fever,  but  I 
believe  them  to  be  nothing  more  than  a  part  of  the  regular 
history  of  the  disease.  We  tind  the  same  thing  true  in  re- 
gard to  many  other  diseases. 

CoMPLiCATioxs  AXD  Sequel.e. — I  coine  now  to  speak  of 
those  conditions  which  may  be  regarded  as  the  sequehc  or 
complications  of  scarlatina.  The  most  common  sequtda  is 
anasarca.  The  anasarca  of  scarlatina  usually  ap})ears  at 
the  time  the  patient  is  convalescing,  during  the  ])eriod  of 
desquamation,  or  just  as  desquamation  is  being  com])leted. 
It  has  been  connnonly  believed  i)y  the  ]»rofession  that  ana- 
sarca is  due  to  some  exposure  to  the  inlluence  of  cold  during 
this  period.  It  is  quite  possible  that  the  chanixcs  in  the 
21 


322  SCAELET    FEVER. 

kidney  wliicli  give  rise  to  the  anasarca  may  sometimes  be 
produced  by  the  influence  of  cokl,  and  undoubtedly  ana- 
sarca is  occasionally  developed  in  this  manner,  but  in  the 
majority  of  cases  it  is  due  to  some  peculiarity  in  the  scarlet 
fever  i)oison,  or  to  some  peculiar  atmospherical  condition. 

During  some  years  anasarca  is  a  very  common  sequela 
of  scarlet  fever  ;  while  during  other  years  we  have  equally 
severe  cases  of  the  disease,  and  yet  scarcely  a  case  of  ana- 
sarca is  seen.  While  we  recognize  the  fact  that  it  is  possible 
for  kidney  lesions  to  be  developed  which  shall  give  rise  to 
anasarca  in  consequence  of  exposure  to  cold,  it  is  also  of 
importance  that  we  recognize  the  fact  that  the  lesions  and  the 
anasarca  may  be  developed  independent  of  such  exposure. 
The  anasarca  first  shows  itself  on  the  face,  and  from  the  face 
it  extends  over  the  entire  body,  and  if  it  becomes  general 
you  will  usually  have  more  or  less  ascites  developed.  In 
most  cases,  at  the  time  or  previous  to  the  occurrence  of 
the  anasarca,  you  will  have  certain  premonitory  symptoms, 
and  it  is  of  great  importance  that  you  should  be  familiar 
with  these  symptoms,  and  be  on  the  watch  for  their  appear- 
ance. For  two  or  three  days  previous  to  their  development 
a  certain  restlessness  will  be  noticed,  with  nausea  and  vomit- 
ing.    These  symptoms  are  almost  universally  present. 

The  nausea  and  vomiting  so  commonly  present  during 
the  earlier  periods  of  the  disease  have  subsided,  and  now, 
during  the  period  of  desquamation  or  perhaps  after  it  has 
been  completed,  the  vomiting  returns.  The  patient  has 
some  pain  in  the  head,  has  loss  of  appetite,  is  annoyed  by 
the  light,  does  not  sleep  well,  and  the  temperature  is  raised 
perhaps  two  or  three  degrees.  When  your  patient  com- 
plains in  this  manner  during  the  desquamative  stage  of  scar- 
let fever,  your  suspicions  should  be  aroused,  and  if  you 
have  not  already  examined  his  urine  you  should  do  so  at 
once.  It  will  usually  be  found  scanty  and  high-colored, 
will  contain  albumen  and  casts  of  the  exudative  variety, 
and  perhaps  blood-casts.  Occasionally,  epithelial  casts  are 
found;  usually,  however,  these  casts  are  not  seen  until  later 
during  the  disease.  If  you  have  made  previous  examina- 
tions of  the  urine  before  the  development  of  these  symp- 


SEQCTEL.E.  323 

toms  you  may  liiive  found  renal  ('])ifli(>limn,  wliidi  an' 
usually  found  in  an}'  seven*  case  of  scarlet  Icvei-;  but  mow 
there  an?  ])n'sent  casts  which  indicate  tin?  (\\ist«'nc('  of  :in 
active  intlainniatory  process  in  the  uriiiift-rous  tubules.  It 
is  not  the  ('])itht'lial  desquamation  oi"  ihc  tubules,  wiiich  oc- 
curs in  connt'ction  with  thi-  (li'S(|uaination  which  is  takiu;; 
place  over  the  riitiif  sui  facr  of  flu'  Inxly ;  but  it  is  a  distinct 
sequela  of  the  disease,  which  shows  itself  in  the  form  of  a 
tubular  uephiitls.  It  is  ])()ssible  to  have  a  i)arenchymatous 
nephiitis  devehqied  in  coiise([Ueiice  of  exposure  to  cold 
durinii"  this  sfauv  c)f  scarlet  fever,  but  this  nephritis  is  due 
to  the  direct  elfect  of  a  ])oison  which  is  acting  upon  the  se- 
creting portion  of  the  kidnevs. 

After  the  anasarca  has  been  present  two  or  three  days,  if 
the  case  is  to  have  a  favorable  termination,  the  anasarca 
will  begin  to  decline,  will  be  less  and  less  marked  about  the 
face  and  feet,  the  tendency  to  stupor  which  has  accom- 
panied it  will  begin  to  disappear  ;  and  as  the  dropsy  sub- 
sides, and  the  patient  is  not  so  lethargic,  the  appetite  be- 
gins to  return,  the  urine  increases  in  quantity,  the  albumen 
diminishes,  the  casts  disappear,  and  convalescence  is  fully 
established.  Anasarca  may  have  been  developed,  all  the 
symptoms  have  disa]>peared,  and  the  patient  have  recov- 
ered within  two  weeks  from  the  commencement  of  the  at- 
tack. Such  anasarca  is  due  to  a  simple  catarrhal  inflam- 
mation of  the  uriniferous  tubules,  and  as  complete  recovery 
may  take  place  as  after  an  ordinary  catarrhal  inflammation 
affecting  the  bronchial  tubes. 

If,  however,  after  the  anasarca  is  developed,  the  case  is 
to  go  on  to  an  unfavorable  termination,  the  anasarca  instead 
of  diminishing  will  increase,  the  face  will  become  more  and 
more  puffy,  the  legs  more  and  more  crdematous,  the  abdomen 
more  and  more  distended,  the  ])ulse  more  and  more  fn'ciuent 
and  feeble,  the  temperature  mure  and  more  elevati-d,  until 
a  condition  of  coma  is  finally  reached,  which  condition  is 
sometimes  preceded  by  convulsions,  and  followed  bv  death. 

I  have  given  you  a  brief  outline  of  the  usual  course  of  a 
case  of  scarlatinal  nephiitis.  wli-'iher  it  goes  on  to  recovery 
or  to  an  unfavorable  termination. 


324  SCARLET    FEVER. 

It  is  possible  for  bronchitis  or  pneumonia  to  occur  as  a 
complication  of  scarlet  fever,  but  they  are  of  rare  occur- 
rence. As  I  have  already  stated  anasarca  is  the  most  com- 
mon sequela,  and  if  you  will  remember  when  and  why  it 
appears  you  will  rarely  fail  to  recognize  its  occurrence. 

Another  sequela  of  scarlatina  is  inflammation  of  the 
serous  memhranes.  The  serous  membrane  most  liable  to 
be  involved  is  the  endocardium,  and  this  inflammation  may 
pass  unrecognized  unless  you  are  on  the  watch  for  its  oc- 
currence, for  there  may  be  no  rational  symptoms  present. 
Endocarditis,  when  it  does  occur,  is  liable  to  be  ulceratim  in 
character.  As  the  result  of  such  ulcerative  endocarditis 
you  may  have  septic  symptoms  developed,  or  embolism  oc- 
curring in  consequence  of  the  removal  of  a  portion  of  mate- 
rial from  the  ulcerated  valve,  and  a  subsequent  plugging 
up  of  an  arterial  twig  in  some  distant  part  of  the  body.  If 
a  portion  is  removed  and  carried  by  the  circulation  into  the 
brain,  and  has  been  lodged  in  one  of  the  cerebral  vessels,  it 
will  give  rise  to  sudden  coma,  and  unless  you  have  been 
very  closely  watching  your  patient  you  may  be  at  a  loss  to 
account  for  the  sudden  development  of  the  embolic  symx3- 
toms  in  a  patient  who  seemed  to  be  doing  well. 

If  the  endocarditis  is  not  of  the  ulcerative  variety,  the 
patient  apparently  recovers  and  you  discharge  him  as  cured 
of  his  scarlet  fever.  Two  or  three  months  after  his  dis- 
charge, he  comes  back  to  you  complaining  of  shortness  of 
breath,  and  probably  you  will  suspect  and  search  for 
chronic  kidney  disease  and  find  no  evidence  of  its  existence, 
but  you  will  find  the  signs  of  chronic  endocarditis,  the  result 
of  the  acute  endocarditis,  which  you  had  failed  to  recognize. 
Inflammation  of  the  pericardium  may  occur  as  a  compli- 
cation of  scarlet  fever,  but  it  does  so  much  less  frequently 
than  inflammation  of  the  endocardium.  Inflammation  of 
tlie  pleura,  and  occasionally  inflammation  of  the  peritoneum 
is  met  with  as  a  sequela  of  this  disease.  I  have  seen  death 
caused  by  an  acute  peritonitis  which  occurred  as  a  sequela 
to  scarlet  fever,  but  if  peritonitis  does  occur  it  is  much  more 
likely  to  be  subacute  in  character.  It  is  possible  to  have 
peritonitis  developed  as  a  sequela  to  scarlet  fever  and  to 


sp:quel/E.  325 

be  ontin^ly  rocovorod  from.  T  liavo  had  two  patients  re- 
cover wlu)  liad  ascites,  tlie  result  of  subacute  jn'ritoiiitis  as 
a  sequela  of  scarlet  fever. 

Klieumatisni  may  be  developed  during  the  d«'squamative 
period  of  scarlet  fever.  Under  such  circumstances  it  assumes 
the  ordinary  a])pearances  of  inflammatory  rheumatism. 
Quite  rapidly  it  invades  one  joint  after  another,  the  joints 
become  red,  swollen,  and  painful,  the  temjx'rature  rises,  and 
the  pulse  becomes  accelerated;  but  the  attack  is  of  sliort  du- 
ration, usually  does  not  last  more  tlian  four  or  five  days. 
It  is  not  a  serious  sequela,  and  complete  recovery  usually 
occurs  within  ten  or  fourt<H'n  days  from  the  commencement 
of  the  attack. 

Suppurative  inflammation  of  the  joints  sometimes  occurs 
as  a  sequela  of  scarlet  fever.  I  have  seen  cases  in  which 
suppuration  of  tlie  knee-joint  occurred  after  convalescence 
had  been  fully  established,  and  all  the  phenomena  of  an  or- 
dinarj^  attack  of  sujipurative  synovitis  were  presented. 
One  case  under  my  care  terminated  in  anchylosis.  Such 
suppurative  inflammation  is  not  of  very  frequent  occur- 
rence, but  it  is  well  you  should  be  aware  of  the  possibilitj' 
of  such  a  sequela. 

Another  serious  complication  of  scarlet  fever  is  diphtheria. 
It  may  occur  at  any  period  of  the  fever,  usually  it  occurs 
during  the  period  of  desquamation.  There  is  developed 
the  characteristic  exudation  of  the  disease,  with  the  atten- 
dant depression  noticed  in  a  case  of  diphtheria  developed 
independently  of  scarlet  fever. 

It  differs  in  no  respect  from  primary  diphtheria,  except  in 
the  ra])idity  of  its  development  and  in  its  fatality.  In  scarlet 
fever  there  is  no  more  serious  complication.  AVhen  I  ob- 
serve a  diphtheritic  patch  in  the  throat  of  a  scarlet  fever 
patient,  from  that  time  I  regard  the  case  as  hopeless. 
Usually  it  appears  quite  suddenly,  and  perhaps  does  not 
occur  more  frequently  in  those  who  have  a  severe  form  of 
the  disease  than  in  those  who  have  a  mild  scarlet  fever. 


LECTURE    XXVIII. 


SCARLET   FEVER. 
Differential  Diagnosis.— Prognosis.— Treatment. 

In  the  history  of  scarlet  fever  we  have  now  come  to  its 
differential  diagnosis. 

Differential  Diagnosis.— The  diagnosis  of  scarlet  fever 
is  usually  not  difficult  after  the  eruption  has  made  its  ap- 
pearance, for,  in  well-marked  cases,  that  alone  will  readily 
distinguish  it  from  the  other  eruptive  fevers.  At  the  very 
onset  of  the  eruption,  and  in  irregular  cases  sometimes  the 
differential  diagnosis  is  difficult.  The  eruptive  diseases 
which  are  most  liable  to  be  mistaken  for  scarlet  fever  are 
measles,  small-ijox,  roseola,  and  an  erytliem.a  which  some- 
times appears  in  surgical  cases.  In  all  doubtful  cases  a 
careful  study  of  the  history  of  the  patient  is  necessary  be- 
fore making  your  diagnosis. 

In  measles  the  appearance  of  the  eruption  is  preceded  by 
a  cough  and  coryza.  These  symptoms  are  never  present  in 
the  ushering-in  stage  of  scarlatina.  Besides,  the  eruption 
of  measles  first  appears  on  the  face,  whereas  the  eruption  of 
scarlet  fever  first  makes  its  appearance  upon  the  neck  and 
chest.  After  these  diseases  are  once  fully  developed,  the 
course  of  the  one  so  differs  from  that  of  the  other  that  there 
will  rarely  be  any  chance  for  doubt  after  the  first  week  of 
the  disease.  The  minute  punctate  appearance  of  the  scar- 
latina eruption  before  it  becomes  conffuent  is  an  important 
element  in  its  diagnosis.  Although  the  eruption  of  conflu- 
ent variola,  for  the  first  twenty-four  hours,  may  sometimes 


1)IKKi:i:i;ntial  I)IA(;\(>>^is.  :{-i7 

resemble  tluit  of  scarlatiun,  yet  the  dcvelopiueuL  of  the  lir^t 
vesicle  settles  the  question. 

The  ap]ieiinince  of  enjlhema  bears  a  closer  resemblance 
to  a  perfi'ctly  developed  scarlatina  eruption  than  does  any 
other  eru})tive  disease.  It  is  not,  however,  present  on  the 
extremities,  neck,  and  portions  of  the  trunk,  and  spreads  in 
a  very  irregular  manner  ;  whereas  in  scarlatina  such  is  not 
the  case.  I5ur  if,  on  account  of  the  scantiness  of  the  scarla- 
tina eruption,  any  doubt  arises  as  to  the  nature  of  the  erup- 
tion, remember  that  in  scarlatina  the  throat  symptoms  are 
rarely  absent,  that  usually  tlie  tongue  presents  the  straw- 
berry appearance,  and  that  at  an  early  period  there  is 
usually  some  swelling  of  the  cervical  glands.  In  those 
cases  in  which,  during  the  early  part  of  the  disease,  it  is 
impossible  to  make  a  differential  diagnosis,  when  the  period 
of  desquamation  is  reached  the  diagnosis  will  be  readily 
made. 

The  differential  diagnosis  between  roseola  and  a  very 
mild  form  of  scarlatina  is  sometimes  attended  with  great 
difhculty.  If  scarlatina  is  prevailing,  and  a  child  has  an 
eruption  which  lasts  for  two  or  three  days,  then  disappears, 
and  is  not  followed  by  desquamation,  you  very  natui-ally 
come  to  the  conclusion  that  the  case  is  one  of  scarlatina ; 
and  yet  the  sequela  proves  that  the  case  was  one  of  roseola. 
Such  a  form  of  roseola  sometimes  prevails  epidemically,  and 
attacks  the  children  in  a  certain  locality,  wh.'ther  they  have 
or  have  not  had  scarlatina.  Under  such  circumstances, 
adults  and  children  are  said  to  have  had  a  second  attack  of 
scarlet  fever. 

In  making  a  differential  diagnosis  between  this  form  of 
roseola  and  scarlatina  you  must  be  guided  by  the  duration 
of  the  eruption  and  by  the  character  of  the  throat  symi>- 
toms.  In  sctirlatina  the  posterior  part  of  the  pharynx  is 
affected,  while  in  roseola  the  redness  is  confined  to  the  an- 
terior portion;  besides,  the  throat  affection  in  roseola  is 
much  milde-r  tha-n  in  scarlatina. 

One  can  hardly  mistake  erysipelas  for  scarlatina,  for 
erysipelas  comnuMices  at  one  point  and  from  that  ix>int 
gradually  extends  ;  there  is  also  marked  a^denui  of  the  con- 


328  SCARLET    FEVER. 

nective  tissue,  and  there  is  a  very  marked  difference  in  the 
constitutional  symptoms  of  the  two  diseases. 

There  are  malignant  cases  of  scarlet  fever  in  which  no 
eruption  appears  ;  they  prove  rapidly  fatal.  In  such  cases, 
you  must  be  guided  in  your  differential  diagnosis  by  the 
fact  that  an  epidemic  of  scarlet  fever  is  prevailing  (which  is 
usually  the  case),  by  the  rapid  development  of  the  disease, 
by  the  very  high  range  of  temperature,  and  by  the  very 
grave  nervous  phenomena  ;  all  of  which  cau  only  be  ac- 
counted for  on  the  ground  that  your  patient  is  overwhelmed 
b}'  some  ver}'"  active  blood-poisoning. 

In  no  other  infectious  disease  do  we  have  such  violent 
sjnuptoms,  nor  does  death  take  j)lace  in  so  short  a  time. 

In  this  class  of  cases  you  should  frequently  examine  the 
entire  surface  of  the  body,  for  the  eruption  is  sometimes 
very  transient,  perhaps  a]3pearing  only  for  a  few  hours  on 
the  neck  or  extremities.  It  is  sometimes  difficult  to  draw 
the  line  of  distinction  between  scarlatina  without  an  erup- 
tion, with  swelling  of  the  cervical  glands  and  ulceration  of 
the  throat,  and  diphtheria.  If  a  patient  has  swelling  of  the 
cervical  glands  and  well-marked  febrile  symptoms,  which 
have  come  on  graduall}^,  that  is,  have  been  two  or  three 
days  developing,  and  yet  no  scarlatina  eruption  has  ap- 
peared, but  a  gangrenous  ulceration  has  developed  involv- 
ing the  tonsils,  the  posterior  wall  of  the  pharynx,  and  the 
anterior  pillar  of  the  soft  palate,  if  scarlet  fever  is  prevailing 
in  the  locality  it  is  very  difficult  to  decide  between  it  and 
diphtheria. 

There  can  be  no  doubt  but  that  scarlatina  poison  may 
excite  a  tubular  nephritis  without  an  eruption  appearing 
upon  the  surface  of  the  body,  or  without  any  of  the  other 
ordinary  symptoms  of  scarlatina. 

Prognosis. — The  prognosis  in  scarlet  fever  is  always  un- 
certain. It  will  be  influenced  more  by  the  character  of  the 
prevailing  epidemic  than  by  any  other  circumstance. 

According  to  statistics,  the  rate  of  mortality  ranges  from 
one  death  in  five  to  one  in  twenty.  Some  epidemics  are  very 
mild.  During  one  epidemic,  in  one  month,  I  treated  fifty 
cases  of  scarlet  fever,  with  only  two  deaths.     During  the 


PfiTiio  month  of  \ho  followiiin*  y»':ir,  I  tivatcd  twi^nty  riisfs 
with  si'vt'ii  (l«'ath:3.  In  iniikiiii^  your  prognosis  you  must 
always  tak.'  into  account  tlio  type  of  the  prevailing  disease. 
Evi'u  when  the  disease  is  mild  in  character,  and  is  running 
a  i)t'rfectly  regular  course,  dangerous  symptoms  nuiy  sud- 
denly arise  without  an}^  assignable  cause. 

The  conditions  of  a  favorable  ]irognosis  are  as  follows  : 
when  th<^  eruption  a])pears  within  fortv-eight  hours  from 
the  eoiniuencement  of  the  attack,  and  ra])idly  completes  its 
course,  reaching  its  maximum  on  the  second  day  ;  when  the 
throat  symptoms  are  mild,  little  difficulty  being  experienced 
in  swallowing  ;  when  the  cervical  glands  an?  but  slightly 
enlarged  ;  when  the  temperature  does  not  rise  higher  than 
104°  F.,  and  the  pulse  beats  only  120  per  minute  ;  when  the 
cerebral  S3^mptoms  are  not  severe, -and  are  of  short  duration  ; 
and  when  the  disappearance  of  the  eruption  is  attended  by 
a  steady  decline  in  temperature.  Even  if  there  i3  a  slight 
affection  of  the  joints  and  a  moderately  severe  nephritis 
during  the  period  of  desquamation,  a  favorable  termination 
may  be  predicted.  The  nephritic  symptoms  will  almost 
always  entirely  disap]>ear  during  the  third  or  fourth  week. 

The  conditions  for  an  unfavorable  prognosis  are:  when 
the  disease  pursues  an  irregular  course  ;  when  tln^  temi)era- 
ture  rises  above  lO.j""  F.,  with  dyspnoea  and  extrenu'  fre- 
quency of  the  pulse  ;  when  sym])toms  of  collapse  come  on, 
attended  by  a  cold  surface  and  a  small  pulse  ;  when  the 
eruption  assumes  a  livid  hue, and  there  are  abundant  IhMuor- 
rhages  in  the  skin  ;  whi'ii  iilctTative  ]ihai}  iigitis  is  present, 
especially  wlieu  it  extends  to  the  nasal  passages,  accom- 
panied b}'  copious  coryza  and  infiltration  of  the  glands  and 
tissues  of  the  neck ;  when  severe  nervous  symptoms  are  de- 
veloped with  tyi)hoid  sym]itoms  ;  when  there  is  persistent 
and  long-continued  vcmiiting,  with  diarrhoea  coming  on  at 
the  commencement  of  the  attack  ;  when  the  nephritic  symp- 
toms are  early  present,  and  there  is  general  drops}',  exces- 
sive ha^maturia,  or  almost  complete  sup])ression  of  urine, 
with  high  temperature. 

The  occurrence  of  any  of  the  more  serious  com])lications 
to  which  I  have  already  refern.'d,  such  as  ])neumonia.  diph- 


330  SCARLET    FETEE. 

tlieria,  pericarditis,  oedema  glottidis,  etc.,  always  renders 
the  prognosis  bad. 

Before  making  your  prognosis,  decide  whether  the  scarlet 
fever  is  regular  or  irregular  in  its  course,  and  if  irregular, 
what  are  the  causes  of  the  irregularity.  By  so  doing,  you 
will  be  greatly  aided  in  making  your  prognosis.  It  is  also 
important  to  determine  your  patient's  power  of  resisting 
disease. 

Favorable  hygienic  surroundings,  good  nursing,  and  well- 
directed  medical  treatment  will  greatly  lessen  the  death-rate 
in  scarlet  fever  epidemics,  and  these  should  be  considered 
elements  of  prognosis.  Patients  with  scarlet  fever  do  better 
when  left  to  themselves  than  when  badly  nursed,  or  when 
under  the  care  of  unskilful  medical  attendants. 

Age  is  an  important  element  of  prognosis. 

The  period  of  greatest  mortality  is  from  infancy  to  five 
years  of  age.  Bej^ond  this  period  until  adult  life,  the  prog- 
nosis is  decidedly  better.  In  adults,  the  mortality  is  great- 
est in  23regnant  women,  and  those  who  are  suffering  from 
some  organic  disease,  especially  some  disease  of  the  heart 
or  kidneys. 

Treat.alejSTT. — In  connection  with  the  treatment  of  this 
affection,  the  first  question  that  presents  itself  relates  to 
pro'pliylaxis  or  x>reT>entlon. 

The  projyhylaxis  of  scarlet  fever  is  a  system  of  the  strict- 
est quarantine.  The  sick  must  be  removed  from  the  healthy. 
As  in  other  exanthematous  fevers,  all  useless  articles  of  fur- 
niture must  be  removed  from  the  sick-room.  Fresh  air 
renders  the  contagion  of  scarlet  fever  less  powerful ;  there- 
fore, free  ventilation  is  of  the  utmost  importance.  All  the 
clothes  and  excretions  of  the  patient  should  be  disinfected 
in  the  same  manner  as  in  typhoid  fever.  To  prevent  the 
dissemination  of  the  dusty  particles  of  the  desquamating 
epidermis,  during  the  period  of  desquamation  the  surface 
of  the  body  should  be  frequently  sponged,  and  after  each 
sponging  the  surface  should  be  rubbed  with  olive  oil. 

Those  convalescing  from  this  disease  should  not  be  allowed 
to  leave  their  apartment  until  desquamation  is  completed, 
which  usually  requires  at  least  three  weeks  after  the  com- 


TKKAT.MKXT.  ^^l 

iiitMicvnionl  of  the  ])('1M(kI  of  (l('s<ju:minti()n.  Tlie  sicl^-ioom 
and  cvt'iytliin^  wliicli  has  Ix-cii  used  al)()Ut  tli<»  ])atit'iit 
ylidiild  he  thoronu^hly  <lisiiir<'ci<'(h  ami  the  windows  and 
doois  of  the  a])artiut'iit  shouI<l  he  aUowcd  to  rtMiiaiii  oj»rii 
for  a  loiiLj  tinif  hefore  it  is  a^i^aiu  occupied. 

To  ]ir('V(Mit  the  spread  of  the  disease,  nurses  and  attcn- 
(hmts  upon  tlie  sIcIn.  sliould  not  be  aliow('d  to  have  any 
intercourse  with  the  Ileal  I  hy  until  the  ])i'iiod  of  desquama- 
tion is  passed,  and  after  that  tinn'  not  until  there  has  been 
tliorouich  cleauinjx  and  disinfrctinu;.  It  is  (h)ubtful  whctlwr 
the  funerals  of  those  d3'ing  of  scarlet  fever  should  be  })ublic. 

There  is  no  known  prophylactic  treatment,  except  iso- 
lation, and  a  thorough  disinfection  of  everything:;  contami- 
nated by  the  contagion. 

A  theory  has  been  advanced  that  belladonna  has  i^^wer  to 
prevent  the  development  of  this  disease  in  those  who  have 
been  exposed  to  its  contagions  influence.  This  drug  has 
been  very  extensively'  administered  in  order  to  test  its  effects 
as  a  preventive  in  scarlet  fever. 

After  having  carefully  examined  the  subject,  both  in  its 
literature  and  clinically,  I  am  convinced  that  belladonna 
has  no  power  to  prevent  the  development  or  mitigate  the 
severity  of  the  fever  in  those  wdio  have  been  exposed  to  its 
infection.  As  I  have  already  said,  fresh  air  is  the  only 
agent  of  which  we  have  any  knowledge,  which  can  nudn- 
the  contagious  influence  of  this  fever  less  powerful. 

Mkdicixal  Treatment. — The  medicinal  treatnn'Ut  of 
scarlet  fever  is  almtDst  entirely  expectant.  It  must  be  re- 
mend)ered  that  it  is  a  disease  which  cannot  be  aborted,  and 
which,  if  left  to  its  natural  course,  tt-nds  to  recovery  if  the 
fever  and  the  local  syniiitonis  r»'main  within  ci-rtain  bonnd<. 
It  has  ct-rtain  stages  to  i)ass  through,  and  you  cannot  safely 
interfere  with  its  regular  course.  Your  })rovin<'e  is  to  stand 
by  and  watch,  and,  so  far  as  possible,  guard  against  com- 
])lications  ;  if  they  occur  you  are  able  to  afford  a  ceitain 
amount  of  relief. 

There  are  certain  details  which  it  is  important  to  attend 
to.  The  bed  and  bod}"  linen  should  be  frequently  changed. 
As  soon  as  the  period  of  des([uamation  has  been  reached  the 


332  SCARLET    FEVER. 

]>ati(>nt  should  have  a  warm  bath  once  or  twice  during  the 
day,  tlie  sni'lace  of  tlio  body  being  well  washed  with  car- 
bolized  soap.  The  baths  hasten  the  process  of  desquamation 
and  aid  in  bringing  the  skin  into  a  healthy  condition  as 
rapidl}-  as  possible  ;  the  kidneys  will  also  be  relieved,  and 
you  may  prevent  serious  lesions  from  these  organs.  Such 
general  means  as  are  applicable  in  the  treatment  of  all  fevers 
may  be  employed.  If  the  temperature  of  the  patient  rises 
above  103°  F.,  certainly  if  it  rises  above  104°  F.,  it  is  impor- 
tant that  some  measures  be  resorted  to  for  its  reduction. 
The  temperature  should  never  be  allowed  to  remain  at  104° 
F.  longer  than  twenty-four  hours. 

The  means  which  are  to  be  employed  to  accomplish  this 
reduction  are  the  antipyretic  measures  already  referred  to, 
such  as  the  application  of  cold  to  the  surface  by  means  of 
sponging  and  baths,  and  the  administration  of  large  doses 
of  quinine. 

There  is  a  strong  prejudice  against  the  application  of  cold 
to  the  surface  of  the  body  in  scarlet  fever.  I  am  by  no 
means  certain  that  cold  baths  are  always  safe,  or  that  in  all 
cases  the  application  of  cold  to  the  surface  is  judicious 
treatment. 

At  the  present  day,  we  are  told  that  the  kidneys  will  be 
most  readily  relieved  of  the  scarlet  fever  poison  when  cold  is 
used  for  the  purpose  of  reducing  the  temperature,  and  that 
we  should  make  use  of  this  agent  rather  than  permit  the 
case  to  go  on  without  effecting  such  a  reduction. 

It  is  claimed  that  when  the  temperature  of  a  patient  is 
kept  below  103°  F.,  scarlatina  nephritis  rarely  occurs.  This 
statement  is  not  sustained  by  facts  ;  it  has  been  found  that 
kidney  complications  are  as  extensive  in  the  cases  where 
cold  is  employed  as  in  those  cases  where  the  temperature 
ranges  higher  and  cold  to  the  surface  is  not  employed. 

We  should  be  governed  by  the  same  rules  in  the  appli- 
cation of  cold  to  the  surface  in  scarlet  fever  as  govern  us  in 
the  treatment  of  typhus  and  typhoid  fevers. 

With  regard  to  the  use  of  quinine  as  an  antipyretic,  I 
need  add  nothing  to  what  has  already  been  said  in  connec- 
tion with  its  antipyretic  power  in  the  treatment  of  other 


TUEATMENT.  'yV-^ 

ft>v.Ms.     It  has  tlie  same  pow.'r  (tf  reducing  teniporatiiit'  in 
scarh't  fever  tliat  it  lias  in  typhoid  h'ver. 

Unless  the  tfiujx'rature  in  a  ease  of  searh't  fever  ranges 
above  105°  F.,  do  not  apply  cold  to  the  siuiace,  noi-  give 
quinine  in  anliiiyretic  doses.  With  sucii  a  lenipeniture 
there  will  prol)al)ly  be  delirium,  but  it  must  be  regarded  as 
one  of  the  phenomena  of  the  disease,  requiring  no  sjx'cial 
treatment.  If  the  tem])eratur(^  rises  above  lO.j"  F.,  perhai)S 
reaches  10(3'  F.  or  107°  F.,  and  the  patient  numifests  the 
nervous  phenomena  which  have  been  referred  to,  such  as 
restlessness,  tossing,  blueness  of  the  surface,  tendency  to 
coma,  etc.,  your  duty  is  to  reduce  the  tem])erature  either 
b}-  the  a])plication  of  cold  to  the  surface  or  by  the  admin- 
istration of  one  or  two  antipyretic  doses  of  (piinine.  In  all 
cases,  let  the  patient  be  sponged  frequently  with  tepid 
water,  and  if  there  is  intense  burning  of  the  surface,  add 
a  saline  to  the  water.  Sponging  in  this  manner  will  give 
the  patient  very  great  comfort.  Some  have  advised  that 
the  surface  be  anointed  with  oil  for  the  relief  of  the  burn- 
ing. My  own  experience  has  led  me  to  rely  upon  simple 
tepid  saline  water.  I  have  found  that  it  gives  patients 
greater  relief,  is  more  easily  a]q3lied,  and  in  its  use  is  more 
agreeable  than  any  of  the  substances  which  have  been  used 
for  this  ]niiiiose.  I  have  not  found  that  the  application  of 
oil  to  tlie  surface  has  any  elfect  in  controlling  the  temi)era- 
ture,  nor  does  it  seem  to  have  any  effect  on  the  process  of 
des(iuaniation,and  as  soon  as  desquamation  commenc(>s,  tlie 
process  should  be  assisted  by  fre([uent  washings  with  soap 
and  water.  For  the  throat  com])lications,  whieh  will  give 
you  more  or  less  trouV)le  in  all  severe  cases,  es})ecially 
when  there  is  much  enlargement  of  the  glands  at  the  angle 
of  the  jaw,  causing  difficulty  in  swallowing,  leeches  were 
formerly  em))loyed,  but  their  use  has  now  been  almost  en- 
tirely abandoned.  The  vitality  of  the  patient  is  lessened 
by  their  use,  and  on  this  account  they  are  contra-indicated. 
Of  all  the  remedies  which  I  have  em])]oyed  for  the  relief  of 
throat  complications,  I  think  <-old  carbonic  acid  water  the 
best.  Whether  it  does  more  than  all'ord  relief,  I  am  not 
able  to  say,  but  I  am  certain  that  cold  carbonic  acid  waii-r 


334  SCARLET    FEVER. 

or  pieces  of  ice  held  in  the  month,  and  brought  as  much  as 
j)ossible  in  contact  with  the  swollen  mucous  membrane  of 
the  throat,  when  used  early,  afford  most  marked  relief. 
In  the  advanced  stages  of  the  disease,  where  there  is  great 
infiltration  of  the  glands  and  tissues  about  the  neck,  cold 
api»lications  do  not  afford  the  same  relief  as  when  they 
are  used  in  the  early  stage;  then  cloths  wrung  out  in 
tepid  water  and  applied  to  the  surface  seem  to  be  of  ser- 
vice. During  this  stage,  hot  applications  are  generally 
much  more  agreeable  to  the  patient.  You  may  cover  the 
hot  cloths  witli  oil-silk.  These  applications  will  not  hasten 
the  suppurative  process,  unless  suppuration  is  already 
established.  While  using  hot  applications  externally,  warm 
water  gargles  and  steam  inhalations  may  be  used  internally. 
Of  these  methods  of  treating  throat  affections,  adopt  the 
one  which  seems  to  you  to  be  the  most  rational  plan  of 
treatment.  In  scarlet  fever  I  favor  the  use  of  hot  rather 
than  cold  applications.  Whichever  you  use,  use  it  to  the 
exclusion  of  the  other ;  either  cold  internally  and  externally, 
or  heat  internally  and  externally. 

There  are  different  opinions  in  regard  to  the  action  of 
heat  and  cold.     Some  claim  that  their  action  is  the  same. 

The  superficial  and  deep  ulcers  which  are  sometimes  seen 
in  the  throat  of  scarlet  fever  patients  can  best  be  treated  by 
spraying  them  with  carbolic  acid,  muriated  tincture  of  iron, 
chlorate  of  potash,  tannic  acid,  or  any  of  that  class  of  reme- 
dies. Whatever  remedy  you  may  choose,  it  can  be  much 
more  successfully  applied  by  means  of  spray  than  by  a 
camel' s-hair  brush  or  a  probang.  Such  local  remedies  thus 
applied  afford  great  relief.  The  pain  from  these  ulcerations 
is  sometimes  very  severe,  and  you  will  be  obliged  to  resort 
to  some  measure  for  its  relief.  Bromide  of  potassium, 
ether,  and  other  anodyne  applications  in  the  form  of  spray 
may  be  made  with  satisfactory  results. 

In  a  certain  class  of  cases,  where  there  is  marked  disturb- 
ance of  the  nervous  system,  accompanied  by  great  depres- 
sion of  the  vital  and  feeble  heart  action,  you  will  be  obliged 
early  to  resort  to  the  use  of  stimulants.  It  is  not  necessary 
to  wait  until  a  certain  stage  of  the  eruption  or  of  the  dis- 


TREATMENT.  .^:?.T 

ease  is  rracln'd  l)i'fui('  cMiiimt'iiciiiir  tlu-ir  :i<lminish"iti(>Ji.  It 
may  be  in'cfssary  to  rrsort  to  tlu-ir  use  within  twdvt'  lioiirs, 
or  even  within  a  less  time,  I'loin  th<'  conunrnctMncnt  of  llie 
attack,  ill  soMif  cases  3''()n  will  r.-ly  almost  cntin-ly  on  tlio 
btMirlicial  t'lVt'ct  that  may  bf  itroducrd  by  the  free  and  rarly 
administration  of  stimulants.  Tlu'  aj)])roach  of  kidiu'V  sf- 
quela  in  scarlet  fever  will  be  indicated  by  the  drvehtpm.-ni 
of  tliose  pi'emonitory  symj)toms  which  precede  the  ana- 
sarca; and  whenever  snch  symptoms  are  develojx-d.  you 
should  ap})ly  dry  or  wet  cups,  according  to  the  c(»nilition 
of  tlie  ])atient,  over  the  region  of  tlie  kidneys,  upon  either 
side  of  tlie  spine.  Apply  thiee  or  four  cups  on  each  side, 
and  follow  their  application  with  hot  fomentations  over  tlie 
kidneys.  At  tln^  same  time  raise  the  temperature  of  the 
sick-room  to  73°  F.  or  74°  F.,  cover  the  body  of  the  ])atient 
with  flannel,  administer  hot-air  or  warm  baths,  and  early 
commence  the  administration  of  diuretics.  Of  these,  digi- 
talis wdll  act  most  favorably.  If  the  anasarca  does  not  dis- 
appear under  the  influence  of  the  digitalis  and  the  other 
means  employed,  calomel  may  be  combined  with  the  digi- 
talis, and  its  use  continued  for  a  few  days.  Why  the 
action  of  diuretics  is  increased  by  having  a  mercurial  com- 
bined with  them  I  am  unable  to  say  ;  but  the  fact  is  well 
established  that,  in  certain  cases — when  the  patient  is  going 
on  from  bad  to  worse,  when  the  anasarca  is  increasing,  the 
tendency  to  coma  is  becoming  more  and  more  marked,  indi- 
cating an  unfavorable  termination  to  the  case,  and  cu])s 
have  been  a])])lied,  hot  baths,  and  diuretics  em]»loyed  with 
no  satisfactory^  result — if  small  doses  of  calomel  aie  cdm- 
bined  with  tlie  diuretics,  and  their  use  continued  for  two  or 
three  days,  th«'  entire  ]>hase  of  tlie  case  may  be  changed. 

In  conjunction  with  the  measures  recommended,  let  the 
patient  drink  as  freely  as  ])o-^sible  of  water.  If  convulsions 
occur,  or  threatening  symi)toms  indicating  the  apjuoach  of 
convulsions,  are  developed,  you  will  be  justilied  in  resort- 
ing to  the  use  of  opium,  either  h3])odermically  or  by  the 
mouth.  Fnder  such  circumstances  the  elTect  of  o]>inm  is 
ofteu  most  satisfactoiy.  ll  luit  only  an-'sts  the  c(.iivulsive 
tendencies,  but  produces  tiie  most  profuse  diaphoresis,  and 


336  SCARLET   FEVER. 

aids  in  restoring  the  renal  functions.  With  this  chass  of 
patients  I  am  confident  that  I  have  saved  life  by  the  timely 
use  of  opium.  In  my  published  articles  on  Bright' s  disease 
I  have  very  fully  discussed  the  subject,  and  given  the  rea- 
sons for  its  administration. 

It  is  unnecessary  for  me  to  detain  you  with  the  special 
treatment  of  the  different  complications  wliich  I  have  stated 
as  liable  to  occur  in  scarlet  fever.  The  treatment  of  each 
complication  will  be  hidicated  by  the  character  and  severity 
of  the  complication. 

There  are  many  other  minor  points  in  the  management  of 
this  disease.  I  have  given  you  an  outline  which  I  think 
will  enable  you  to  fully  appreciate  the  general  indications, 
and  I  must  leave  many  of  the  details  of  treatment  to  your 
own  study  and  experience. 


LECTURE   XXIX. 


MEASLES. 

3forb id    A natomy.  — Etiology.  — Symptoms. 

^YE  now  come  to  the  study  of  another  exantliematous 
fever,  namely,  measles  or  niheoJa.  This  is  of  much  more 
frequent  occurrence  tlum  any  of  the  fevers  which  have  been 
engaging  our  attention.  It  is  a  disease  from  which  few  per- 
sons escape.  It  is  essentially  a  disease  of  cliildliood,  but  it 
may  occur  at  any  age  ;  it  is,  however,  less  liable  to  occur  in 
young  infants  than  in  children  after  the  period  of  dentition. 
A  second  attack  is  of  rare  occurrence.  It  is  characterized 
by  an  eruption  of  red  spots,  accompanied  by  a  catarrh  of 
the  mucous  membrane  of  the  air-passages,  and  a  more  or 
less  severe  fever.  It  may  prevail  as  an  e])idemic  or  endemic 
disease,  and  not  infrequently  there  are  sporadic  cases  of 
measles. 

Morbid  Axatomy.— The  anatomical  lesions  of  measles, 

with  the  exception  of  the  eru])tion,  are  similar  to  those  of 

small-pox  and  scarlatina.     There  are  the  same  changes  in 

the  blood  ;  it  is  dark-colored  and  flnid,  poor  in  fibrin,  and  in 

severe  cases  shows  a  tendency  to  infiltrate  the  tissues.     The 

number  of  red  globules  are  diminished,  and  the  white  ones 

are  increased.     There  is  the  same  tendency  to  congestion  of 

the  internal  organs.     The  spleen  and  liver  are  moderately 

enlarged.     The  mucous  membrane  of   the   nose,   ])liaryn.\', 

larynx,  and  larger  bronchi,  as  well  as  the  conjunctivae,  are 

more  or  less  intensely  congested,  and  ])ri',sent  all  the  ana- 
2-2 


338  MEASLES. 

tomical  changes  of  acute  catarrh.  In  the  majority  of 
instances  this  catarrh  is  most  severe  just  before  and  during 
the  early  period  of  the  eruption;  generally,  it  begins  to  dis- 
appear when  the  eruption  has  reached  its  height,  and  within 
two  or  three  days  entirely  disappears.  Where  death  has 
resulted  from  measles,  in  the  majority  of  autopsies  you 
will  find  evidences  of  capillary  bronchitis,  and  not  infre- 
quently evidences  of  catarrhal  pneumonia.  Strictly  speak- 
ing, these  are  not  anatomical  lesions  of  measles,  but 
complications  ;  they  are,  however,  such  frequent  attendants 
of  this  disease,  that  they  almost  become  a  part  of  its  his- 
tory. Catarrhal  affections  of  the  respiratory  organs  are 
rather  characteristic  of  the  measles.  The  eruption  of 
measles  is  papular ;  the  papules  first  show  themselves  upon 
the  face,  especiallj^  upon  the  chin  ;  gradually  they  extend  to 
all  parts  of  the  body,  until  lastly  they  are  seen  upon  the 
back  of  the  hands.  When  the  eruption  is  well  developed 
the  spots  are  slightly  elevated,  and  have  a  diameter  varying 
from  one-tentli  to  one-twentieth  of  an  inch  ;  in  form  they 
are  crescent-shaped,  their  margins  are  sharply  defined, 
usuall}^  their  color  is  of  a  bright  red,  sometimes  shading  off 
into  blue.  In  most  cases  the  spots  are  distinct  and  sepa- 
rated from  each  other  by  pale  tracts  of  skin ;  the}^  may 
become  confluent,  and  thus  give  to  the  surface  an  uniform 
redness.  When  this  occurs  the  surface  presents  an  appear- 
ance similar  to  that  seen  in  scarlatina.  The  earlier  papule 
in  each  spot  usually  occupies  the  place  of  a  hair-follicle. 
The  spots  disappear  on  pressure,  but  immediately  return 
when  the  pressure  is  removed.  Sometimes  each  spot  con- 
tains several  papules.  The  diversity  in  form  and  appearance 
of  measle  spots  in  different  cases  depends  upon  deviations 
in  size,  elevation,  and  grouping  of  the  papules.  When  the 
spots  assume  a  dark-red  color,  and  do  not  disappear  on 
pressure,  capillary  hemorrhages  have  taken  place  into  the 
papules,  and  the  eruption  is  called  hemorrhagic.  When 
the  eruption  is  very  abundant,  little  vesicles  sometimes 
appear  upon  the  papules,  especially  upon  the  trunk  when 
there  has  been  profuse  perspiration.  As  soon  as  the  spots 
have  reached  their  maximum  of  development,  their  color 


KTIOT.OCV.  n^O 

l)(\u-iiis  to  fndc  ;  iln'  fadiinj;  is  ])ro^ivssi\'t',  llu^  ct'iih'"-  of  tin* 
S})urs  loii^ii'cst  rt'taiii  llii-ir  icdm-ss;  (lie  clcvalioiis  subside 
witli  loss  of  color.  In  a  varyiiiLT  liiiH',  rioiu  oiw  to  live  days, 
the  sjK)|s  fiilii'"-!  y  disaj)])i'ai\  li'a\iiii:  a  y<'ll<»\\i^li  oi'  Ihow  iii-li 
stain.     This  staiiiiiiii;  is  due  to  jiit^iin'iilatiMii  of  the  skin,  and 

is  sonictimcs  visible  for  two  weeks.       Ivxfdiialion  of  tl ]>i- 

denuis  or  desciuamalion  lakes  |)la('e  only  u])mii  (he  sid'S  of 
the  nieasle  s])ots  ;  it  is  never  so  extensive  as  in  scarlet  U'Vi'V. 
The  skin  does  not  desquamate  in  layers,  but  in  line  brown 
scales.  It  may  commence  before  (he  rednessof  the  .Mii]tlioii 
disa})])ears,  but  it  does  not  usually  occur  until  the  eiuji- 
tion  lias  entirely  faded.  In  most  cases  the  period  of  des- 
quamation is  short,  rarely  lasting  a  week. 

Etiology. — As  n^g'ards  theeti(^lo<xy  of  measles,  experience 
teaches  tliat  it  is  essentially  a  contagious  disease.  So  far 
as  has  yet  been  determined,  it  is  only  propagated  by  con- 
tagion. Thei'e  are  places,  extensive  districts,  and  conntii''S 
thickly  inhabited,  where  this  disease  has  never  prevailed. 
There  is  no  authentic  evidence  that  it  ever  originated  Sjjoti - 
taneonsly. 

A  few  years  ago,  one  of  our  own  countrymen  announccMJ 
that  he  had  found  in  decaying  straw  a  peculiar  growth  or 
fungus  which  had  the  power  of  developing  measles. 

During  the  late  war  we  frequentl}^  heard  of  "straw 
measles.''  AVhen  the  surface  of  the  body  was  brought 
in  contact  with  a  fungus  found  upon  decaying  straw,  an 
eruption  was  developed.  The  eruption  was  not  that  of 
meash^s.  It  had  no  power  of  propagating  itself,  and  <ould 
not  be  conveyed  from  one  individual  to  another. 

Tlie  question  has  often  been  asked,  wlnie  is  the  poison 
of  measles  located  ?  I  answer,  either  in  the  mucous  si'cre- 
tion,  or  in  the  exhalations  from  the  body  of  the  infected,  so 
contaminating  tlie  air  about  the  sick,  that  when  persons 
who  have  not  had  the  disease  are  brought  within  its  inllu- 
ence,  measles  will  be  developed.  It  has  been  proved  that 
the  blood,  the  mucous  secretions,  and  even  the  tears  have 
the  power  of  conveying  the  disease  by  inoculation.  T  sup- 
pose there  is  little  qii(>stion  but  that  the  disease  caji  ])e  con- 
veyed in  i'lothing,  or,  in  otli'i- woids,  that  it  is  a  portable 


340  MEASLES. 

disease.  I  regard  the  infection  of  measles  as  more  tena- 
cious, so  to  si)eak,  than  that  of  small-pox  or  scarlet  fever. 
That  is,  a  person  not  protected  when  exposed  to  measles  is 
much  more  certain  to  contract  the  disease  than  is  an  unpro- 
tected person  to  contract  small-pox  or  scarlet  fever,  the 
same  circumstances  surrounding  the  exposure.  It  is  pos- 
sible for  the  infection  to  be  conveyed  from  one  place  to 
another  in  clothing  and  in  fluids.  I  know  of  one  instance 
in  which  it  was  brought  to  a  family  in  cow's  milk.  The 
exact  nature  of  this  poison  is  still  unknown. 

It  has  been  claimed  that  a  certain  cell  has  been  found,  a 
cell  Avith  a  tail-like  end,  movable  and  colorless,  which  has 
the  power  of  developing  measles,  but  these  statements  have 
never  been  substantiated,  and  like  the  theory  that  the 
syj)hilitic  cell  was  the  active  agent  in  the  development 
of  syphilis,  this  theory  of  development  still  lacks  facts  to 
sustain  it. 

The  microscope  has  not  as  yet  revealed  the  contagion  of 
this  disease.  All  that  can  be  said  vdth  positiveness  concern- 
ing its  nature  is,  that  there  is  an  impalpable  virus  which 
may  be  conveyed  from'  an  affected  to  an  unaffected  person, 
and  when  received  into  the  body  of  an  individual  who  is 
not  protected  from  the  contagion  by  a  previous  attack, 
after  a  certain  period,  varying  in  length  from  eight  to  four- 
teen days,  it  produces  the  phenomena  which  characterize 
the  disease.  Some  claim  that  the  poison  may  remain  sixteen 
days  in  the  system  before  the  phenomena  of  the  disease 
are  developed.  One  case  is  recorded  in  which  the  disease 
is  said  to  have  been  developed  fifty  days  after  exposure. 

This  period  is  termed  the  "  period  of  incubation,"  audits 
average  duration  is  eight  days.  During  this  period  the 
poison  remains  latent,  giving  its  possessor  no  knowledge  of 
its  presence. 

In  most  cases  a  slight  exposure  is  sufficient  to  induce  the 
disease  ;  in  some  cases  it  is  contracted  only  after  prolonged 
exposure. 

Susceptibility  to  this  contagion  is  almost  universal.  All 
classes  are  equally  subject  to  the  infection.  Second  attacks 
are  exceedingly  rare. 


symi'thms.  341 

Till'  cxnct  tiiut'  ill  tlic  course  of  iIk*  disease  wln-n  nwasl^'S 
is  most  infectious  is  not  drliuili'ly  detcrniincd.  Sialistics 
furnish  almost  absolute  jtroof  that  it  ma>  infect  throUL^h- 
out  its  entire  course,  in  the  ])recursory,  eru})tive,  and  des- 
(luamative  stage. 

Sv.MP'ro>[S.  —  Nfeiisles,  like  t  jic  <  >t  lier  exaut  hemat<tUS  fevel'S, 

if  uiiconijilicated,  iiins  a  definite  course.  I  shall  describe 
the  course  of  an  uncomplicated  cas(^  of  ordinary  severity. 

As  I  have  already  stated,  the  .stttf/e  of  incubation  is  the 
latent  period  of  the  disease,  without  fever,  and  free  from 
h)cal  symptoms. 

Prcrnoiutori/  or  precursur//  staf/c. — At  the  end  of  this 
period,  or  from  eight  to  ten  days  after  exposure,  the  pa- 
tient begins  to  suffer  from  coryza,  is  languid,  chilly,  and 
exceedingly  irritable.  Occasionally,  in  young  children, 
convulsions  occur.  The  corj'za  and  otlier  catarrhal  symp- 
toms, at  first,  may  or  may  not  be  accompanied  by  fever. 
Very  soon  they  will  be  followed,  if  they  are  not  accompanied, 
by  a  marked  febrile  movement.  The  eyes  will  be  injected 
and  watery,  there  will  be  a  burning  siMisation  and  an  aver- 
sion to  light,  and  the  eyelids  will  be  red  and  tumefied. 
Tliere  is  a  constant,  irritating,  watery  discharge  from  tlie 
nose,  with  frequent  sneezing  and  pain  over  the  frontal  si- 
nuses. Sore  throat  is  complained  of,  and  the  voice  is  a  little 
liusky.  Bronchial  catarrh  is  indicated  by  uneasiness  and 
constriction  over  the  chest,  with  a  frequent,  dry,  hoarse 
cough,  hurried  resjnration,  etc.  The  suffused,  red  a])])ear- 
ance  of  the  ej^es  is  peculiar,  and  distinguishes  measles  from 
scarlet  fever  and  other  forms  of  eruptive  fever.  After  the 
early  symptoms  have  continued  perhaps  for  twenty-four 
hours,  perha])s  no  more  than  two  or  three  hours,  an  initial 
fever  will  be  developed,  which,  with  the  catarrhal  symp- 
toms, continues  for  about  forty-eight  hours;  then  the  erup- 
tion makes  its  appearance. 

Eruptive  stage. — The  eruption  is  first  seen  ujion  the  face, 
tlien  upon  the  neck,  then  upon  the  chest  and  over  the  body, 
afterwards  upon  the  legs  and  arms,  and  lastly,  ujion  the 
back  of  the  hand.  Usuall}' it  is  about  four  days  from  the 
time  of  the  a]ipearance  of  the  erujttinn  u])on  the  face  be- 


342  MEASLES. 

fore  it  has  passed  over  the  entire  body,  and  it  begins  to 
fade  from  any  one  part  about  thirty-six  hours  from  the 
time  of  its  appearance  upon  that  part ;  first,  it  begins  to 
fade  from  tlie  face,  then  the  neck  and  chest,  and  finally 
from  the  back  of  the  hands.  If  you  closely  examine  the 
iTujjtion  it  will  be  found  composed  of  little  fine  red  dots, 
which,  after  a  little  time,  will  be  seen  crowded  together  in 
patches  of  irregular  shape.  Usually  these  patches  are 
crescentic  in  shape,  and  between  them  will  be  skin  having 
its  natural  appearance.  In  this  respect,  the  eruption  dif- 
fers from  that  of  scarlet  fever.  In  scarlet  fever  there  is  a 
uniform  blush  or  redness,  and  when  the  eruption  is  present 
no  portion  of  the  skin  remains  unaffected. 

The  eruption  of  measles  presents  more  of  a  papillary  ap- 
pearance upon  the  face  than  upon  any  other  part  of  the 
body. 

With  the  appearance  of  the  eruption  there  is  more  or 
less  swelling  of  the  surface,  itching  and  burning,  and  the 
color  of  the  eruption  w'ill  vary  from  a  bright  rose  red  to  a 
dark  mahogany  hue.  The  difference  in  color  depends  upon 
the  condition  of  the  individual  and  the  peculiarity  of  the 
type  of  the  disease,  rather  than  upon  any  change  in  the 
skin  itself.  As  the  eruption  disappears  it  loses  its  bright 
red  color,  and  becomes  a  yellowish-red,  until,  finally,  noth- 
ing but  a  staining  of  the  surface  is  left,  then  desquamation 
commences. 

Desquamative  Stage. — The  desquamation  which  follows 
the  eruption  is  not  like  the  desquamation  of  scarlet  fever, 
occurring  in  patches,  but  it  occurs  in  very  fine  dust-like 
flakes,  which  may  pass  unobserved.  The  eruption  reaches 
its  height  by  the  third  day  from  the  time  of  its  appearance, 
and  generally  has  disappeared  by  the  end  of  the  sixth  day. 
As  a  rule,  during  the  development  of  the  eruption,  the 
catarrhal  symptoms  and  fever  are  increased  in  intensity  ; 
the  patient  will  sneeze  and  cough,  and  frequently  with  such 
severity,  and  with  such  a  coarse,  grating,  brassy  tone,  that 
it  has  received  the  name  of  '■''iron  cough.''''  It  is  not  the 
cough  of  croup,  there  is  no  stridulous  breathing  accomj^a- 
nying  it,  but  it  is  the  result  of  an  ordinary  catarrhal  laryn- 


IRPwEr.  T'  L  A  VA'U  F.S.  '.U3 

j^:itis,  wliicli  caiis.'S  tlif  ]>:itit'iit  to  cough  pt'rlia])S  for  two  or 
tliivc  (Itiys  without  ('X])i'('t()ration,  or  any  att('ini)t  at  I'XjjfC- 
loration.  During  this  jii-iiod  tlir  ])ulst'  will  raiig<'  from  100 
(o  120  bi-ats  }HT  iiiiimh'.  aii<l  in  yoiiii^  childron  may  roach 
100  beats  })('r  miiuitc  hi  lli<'  majority  of  cases,  tht'  tempe- 
i-atiin'  docs  not  rise  above  HKi  F.,  but  it  may  rise  as  high  as 
1<>0'  F.  or  107  F.  As  soon  as  the  ernjiiion  begins  to  decline, 
a  marked  eil'ect  will  be  ])roduced,  and  usually  the  tem])era- 
ture  falls  two  or  three  degrees.  As  the  decline  in  the  erup- 
tion goes  on.  tlie  temperature  gra<lnally  falls,  nntil.  by  the 
time  the  erniition  has  entirely  disappeared,  the  patient  will 
be  fully  convalescent. 

Such  is  a  brief  description  of  the  eruption,  and  the  symp- 
toms accompanying  it,  wlien  measles  runs  its  regular  course. 
There  are  certain  irregular  modes  of  developnu-nt  which  you 
will  do  well  to  remember. 

We  have  different  varieties  of  measles,  if  we  may  regard 
them  as  varieties. 

We  have,  first,  the  regular  form  of  measles,  which  we 
have  just  been  considering,  in  which  the  disease  runs  a 
regular  course,  and  the  eruption  has  its  regular  stages  of 
development.  Then,  when  measles  is  prevailing  in  a  local- 
ity, you  will  meet  with  cases  in  which  all  the  catarrhal 
symptoms  of  the  disease  are  present,  without  an  erui)tion. 
You  will  also  meet  with  cases  in  which  there  is  an  erui)tion 
closely  resembling  that  of  measles,  with  no  catarrhal  symp- 
toms;  from  the  appearance  of  the  eruption,  you  will  not  be 
able  to  say  whether  the  patient  has  or  has  not  measles;  if 
he  has  been  exposed  to  the  contagion  of  the  disease  you 
will  be  inclined  to  regard  the  case  as  one  of  measles,  and 
yet  if  there  are  no  catarrhal  symi)toms,  but  simpl}^  an  erup- 
tion. I  should  hardly  be  willing  to  make  such  a  diagnosis. 
There  is  a  form  of  roseola  which  very  closely  resembles 
measles  in  every  as])ect  of  the  disease,  except  the  catarrhal 
symptoms. 

There  is  an  irregular  form  of  measles  which  prevails  ejii- 
di-mically,  which  is  characterized  by  a  tendency  to  ulcera- 
tion of  mucous  surfaces.  This  form  shows  its  pectiliar  ten- 
dency by  the  development  of  ulcers  at   the  angle  of  the 


344  MEASLES. 

montli,  within  the  nose,  around  the  vulva,  anus,  etc.  Some- 
times these  ulcers  spread  and  so  interfere  with  deglutition 
and  respiration  as  to  endanger  life.  The  ulcerations  are 
accompanied  by  great  prostration  of  the  vital  powers  and  a 
tendency  to  gangrene.  This  irregular  variety  only  occurs 
in  those  who  are  poorly  nourished,  live  in  badly  ventilated 
houses,  and  are  surrounded  by  unfavorable  hygienic  influ- 
ences. 

Again,  there  is  another  form  of  measles  in  which,  at  the 
very  onset  of  the  disease,  there  is  a  very  high  range  of 
temperature.  You  will  have  no  more  severe  catarrhal 
symptoms  than  in  the  ordinary  forms — no  more  bronchitis  ; 
but  there  will  be  more  fever  and  a  higher  range  of  tem- 
perature, the  temperature  perhaps  ranging  as  high  as  106° 
F.  or  107°  F.  Associated  with  this  elevation  of  tempera- 
ture, there  will  be  a  restlessness,  a  dry  tongue,  and,  very 
soon  after  the  appearance  of  the  dry  tongue,  a  change  in 
the  color  of  the  eruj^tion,  and  it  will  assume  a  dusky,  pur- 
plish hue.  The  eruption  may  present  this  peculiar  appear- 
ance at  the  very  commencement  of  its  development.  This 
type  of  measles  is  called  '"'■black  measles.^''  The  color  of 
the  eruption  simply  shows  that  there  have  been  extensive 
blood-changes.  In  most  cases,  quite  probably,  these 
changes  have  taken  place  prior  to  the  development  of  the 
eruption.  By  some  it  has  been  claimed  that  there  is  at 
work  a  peculiar  epidemic  or  endemic  influence  that  gives 
rise  to  the  peculiar  type  of  the  disease  ;  but,  as  I  have  been 
brought  in  contact  with  it,  it  has  seemed  to  me  that  it  dif- 
fered from  the  ordinary  type  only  in  the  intensity  of  the 
fever.  It  is  the  high  range  of  temperature  which  stamps  it 
as  a  peculiar  type  of  the  disease  ;  but,  as  soon  as  the  erup- 
tion has  made  its  appearance,  although  at  first  it  may  be  of 
a  bright  red  color,  within  a  day  or  two  it  assumes  the 
peculiar  dusky  black  appearance  which  has  given  rise  to 
the  name  it  has  received. 

There  is  another  irregular  form  of  measles,  in  which  the 
eruption  is  largely  made  up  of  petechial  spots  scattered 
over  the  surface  of  the  body,  which  are  due  to  a  hemor- 
rhagic diathesis.    It  is  really  a  hemorrhagic  form  of  measles, 


COMl'LICATION'S.  '.iW> 

and  is  a  v<'rv  uiifavoial)!.'  \y\u-  of  lli.-  disoaso.  At  lirst  the 
eni))ti(Hi  ]»rt>s<'nts  tlif  suiiif  appearance  as  the  onliiiaiy 
erui)ti()ii  of  luraslcs;  but,  aftn-  tlir  fever  lias  coiitimu'd  a 
few  days,  it  assumes  a  daik  color,  the  patient  hfcomes 
restless,  the  ton.«;iie  dry,  tli.  iv  may  be  voniitin^^  and  diai-- 
rhani,  and,  if  death  occurs,  at  the  ])ost-ni()rteni  examination 
3'ou  will  lind  that  the  anatomiT-al  lesions  very  closely  re- 
semble those  found  at  the  ])ost-morteni  examinati(ui  of  one 
who  has  died  from  tyjOioid  fever,  such  as  changes  in  the 
s])leen  and  elevation  of  Peyer's  ])atclies.  These  cases  are 
also  known  by  the  term  "  black  measles."  We  have,  then, 
two  forms  of  black  mr'asles — one  in  which  the  erujttion 
consists  of  petechial  s})Ots  scattered  over  the  surface,  and 
dependent  upon  a  hemorrhagic  tendency  ;  in  the  other 
form  the  eruption  assumes  a  dark  appearance,  on  account 
of  changes  wMiich  have  occurred  in  tht?  blood,  the  result  of 
a  very  high  degree  of  temperature  at  an  eaily  })erio(l  of  the 
attack. 

I  have  thus  l)iieny  spoken  to  you  of  the  most  frequent 
irregularities  in  the  course  of  this  disease.  There  is  always 
more  or  less  danger  connected  with  any  of  the  more  severe 
forms  of  irregular  develo})Uient.  Although  measles  is  usu- 
ally not  a  disease  of  much  severit}^  yet  you  must  remember 
that,  however  mild  the  ty])e  may  be,  the  disease  is  liable  to 
be  complicated,  and  the  most  fretpient  complications  are  to 
be  found  in  tlie  respiratory  organs. 

CoMi'LiCATioxs.— Of  these  the  most  important  is  ca])illary 
bronchitis.  You  will  rarely  have  a  case  of  measles  without 
more  or  less  bronchial  catarrh,  but  the  bronchial  catarrh 
which  ordinarily  attends  it  is  not  of  much  conse([uence. 
When,  however,  you  lind  that  the  broiu-hitis  is  l)ecoming 
cai)illary,  you  must  recognize  the  fact  that  the  patient  is  in 
great  danger.  Ui)on  auscultation,  if  instead  of  loud, 
sonorous  rales,  which  indicate  that  the  catarrh  is  conlined 
to  the  larger  bronchial  tubes,  you  have  line  crackling 
sounds,  accompanied  l)y  aii  entire  loss  of  or  an  extremely 
feeble  vesi<,'ular  murmur,  you  may  be  certain  that  the  ca- 
tarrhal intlammation  has  extended  into  the  finer  bronchial 
tul)es,  and  when,  in  connection  with  this  disease,  these  are 


346  MEASLES. 

invaded,  you  should  remember  that  there  is  always  great 
danger  of  the  plugging  up  of  the  fine  bronchial  tubes. 
Tliis  will  almost  certainly  be  followed  by  a  lobular  collapse, 
and  a  subsequent  development  of  lobular  pneumonia. 

A  catari'hal  pneumonia  which  complicates  measles  is 
always  attended  with  great  danger. 

As  a  rule,  it  attacks  bofli  lower  lobes  at  the  same  time, 
especially  their  dorsal  asjject,  while  in  the  upper  lobes  only 
a  few  tubes  are  involved.  This  complication  may  occur  at 
any  time  during  the  course  of  measles,  but  it  is  more  liable 
to  occur  just  after  the  eruptive  stage.  Its  development 
always  increases  the  fever  in  proj)ortion  to  the  extent  of 
lung  involved. 

Desquamative  nephritis  may  occur  as  a  complication,  but 
is  not  of  as  frequent  occurrence  as  in  scarlet  fever.  You 
will  rarely  have  anasarca  or  the  other  attendants  of  scar- 
latinal nephritis. 

Secondary  meningitis  not  infrequently  occurs  as  a  com- 
plication in  measles.  When  it  does  occur,  it  is  developed 
during  the  period  in  which  the  eruption  is  disappearing.  It 
is  more  likely  to  occur  in  this  disease  than  in  scarlet  fever. 

In  connection  with  measles  you  will  have  what  may  be 
regarded  as  a  sequela,  a  mild  form  of  oj^hthalmia.  This 
ophthalmiamay  considerably  inconvenience  the  patient,  and 
lead  to  permanent  injury  of  the  eyes.  It  is  especially  im- 
portant that  you  should  remember  that  it  appears  during  the 
convalescing  period,  that  it  is  a  conjunctivitis,  and  usually 
entirely  disappears  if  the  eyes  are  frequently  bathed  with 
warm  water  and  properly  protected  from  the  light, 

Otorrhoea,  or  inflammation  of  the  external  ear,  is  another 
complication,  or  rather  sequela  of  measles.  It  most  com- 
monly appears  in  those  j)atients  who  have  what  is  called  a 
strumous  diathesis,  have  phthisical  parents,  are  themselves 
badly  nourished,  and  have  suffered  from  a  severe  form  of 
measles.  This  otorrhoea  is  sometimes  very  obstinate,  and 
if  it  jdelds  to  treatment,  does  so  very  tardily. 

In  adults,  acute  miliary  tuberculosis  not  infrequently 
occurs  as  a  sequela  of  measles.  This  is  the  unqualified 
statement  of  the  books. 


COMPLICATIONS.  IM? 

Williiii  till'  jxist  two  y.'Mis  I  liiiv.' s.'.'ii  two  ciiscs  of  wli:it, 
pivvioiis  to  death,  smut'd  to  he  acute  tiil)erculosis,  and 
when  the  autop^}'  was  made,  throughout  the  lun^:  sub- 
stance here  and  thei-e  were  little  i)oints  or  ii(mIu1<'>  which 
presented  tlie  usu:d  ai)}iearance  of  niiliary  tuberch-s,  l)Ut, 
when  niicroscoi)ically  examined,  they  were  found  to  he 
points  of  vesicular  itiieiuiionia.  These  two  patients  really 
died  I'roni  i)neumonia,  and  not  from  acute  tul)ercuh>sis, 
although  the  lungs  presenttnl  the  a})pearances  ordinarily 
seen  in  connection  wdth  acute  tuberculosis. 

The  gross  ap])ea ranee  of  the  lungs  so  closely  resembles 
lungs  that  are  the  seat  of  acute  tuberculosis,  that  it  is  diffi- 
cult with  the  naked  eye  to  distinguish  tlie  one  from  the 
other. 

The  mucous  membrane  of  the  intestinal  canal  may  also 
become  tlie  seat  of  important  complications  in  measles.  A 
mild  form  of  gastric  catarrh  is  of  quite  frequent  occurrence, 
but  is  rarely  serious  in  character.  Severe  intestinal  catarrhs, 
giving  rise  to  troublesome  diarrhoea  and  dysentery,  are 
sometimes  very  serious  complications,  especial I3'  in  very 
young  and  feeble  children.  Occasionally  malignant  e})i- 
demics  of  measles  prevail,  during  which  fatal  results  are 
chiefly  due  to  intestinal  catarrhs. 

Diphtheria  does  not  so  frequently  comi)licate  measles  as 
it  does  scarlet  fever.  It  generally  makes  its  ai)pearance  at 
the  acme  of  the  eruption,  and  when  severe  its  occurrence  is 
marked  by  a  raj)id  rise  in  temi)erature.  The  symptoms  of 
the  di])htii(^ria  are  the  same  as  when  it  occurs  as  a  ])rimary 
disease.  Inspection  shows  the  dii)htheritic  exudation  on 
the  tonsils  and  pharynx,  accom])anied  by  all  the  atti'Fidant 
phenomena  of  ordinary  dii)htiieria.  Sometimes  the  diph- 
theritic exudation  appears  on  the  labia  of  the  female,  and 
on  the  genitals  of  the  male.  It  must  always  be  regarded  as 
a  serious  complication. 

Not  unfrequently  measles  leaves  the  patient  in  a  state  of 
general  ill-health.  Especially  is  this  the  case  in  scrofulous 
and  racliitic  children. 


LECTURE    XXX. 


MEASLES. 


Differential    Diagnosis.  — Prognosis. — Treatment.  — Rose- 
ola.— Miliary  Fever. 

We  will  continue  the  liistoiy  of  measles,  and  tliis  morn- 
ing I  invite  your  attention  to  its  differential  diagnosis. 

DiFFEKENTiAL  DIAGNOSIS. — Ordinarily,  when  the  erup- 
tion is  well  delined,  the  diagnosis  of  measles  is  not  difficult. 
In  some  cases,  however,  the  ernption  presents  an  appear- 
ance which  closely  resembles  that  of  the  eruption  of  scarlet 
fever  and  roseola. 

As  I  have  already  stated,  in  nearly  every  case  of  measles 
the  catarrhal  symptoms  j)recede  and  accompany  the  pre- 
cursory stage,  and  increase  in  severity  during  the  period 
of  eruption.  The  presence  or  absence  of  these  catarrhal 
symptoms  will  enable  you  in  the  majority  of  cases  to  make 
a  differential  diagnosis. 

It  has  been  said  that  the  line  of  distinction  between 
measles  and  scarlet  fever  may  be  easily  drawn  ;  that  if  in 
scarlet  fever  3^011  j)ass  your  finger-nail  lightly  over  any  por- 
tion of  the  surface  of  the  body,  a  white  line  will  remain, 
which  will  immediately  again  become  red.  Whereas  in 
measles  no  mark  will  usually  be  left  ;  but,  if  a  white  line 
does  remain,  the  color  produced  is  more  permanent  than  in 
scarlet  fever.  In  well-marked  cases  this  appearance  may 
settle  the  question  of  diagnosis,  but  in  those  cases  in  which 
the  eruption  of  measles  closely  resembles  that  of  scarlatina, 


DIFFERENTIA T.    DIAriXOSIS. — rPvOONOSIS.  349 

W(»  are  c(nni)t'llr<l  to  nly  ui»<»m  tlie  prescnri'  oi-  ;jl)s<'iic(' of 
futanlial  sym])t()iiis  and  tlif  ai)i)<'araii('<' of  tin*  tlir(»at.  lii 
cliildivn,  the  eriiptioii  of  ty])hus  ffVfi-  very  frftiu«ritly 
elosely  resembles  tliat  of  measles,  l)nt  it  (lo«'s  not  ajt])' ar 
Ilium  the  face,  ami  is  not  arconii>ani<'(l  by  eatanlial  syiii))- 
toiiis.  In  tyi)hus  fevi-r,  (|uiti'  frfi|ii<'iitly,  ihtvoiis  symit- 
toms  are  present,  such  as  dfliiium,  ])rostration.  and  t'-ii- 
dency  to  coma.  Such  symptoms  are  only  met  with  in  the 
liemorrliagic  or  tyi)hoid  variety  of  measles.  Before  the  aj)- 
pearance  of  the  erui)tion  a  careful  examination  of  the  mu- 
cous membrane  of  the  pluuynx  will  settle  the  question  of 
diagnosis.  In  measles  the  mucous  surface  will  be  more  or 
less  intensely  injected  ;  in  t\plius  fever  it  will  not  be  so 
injected. 

The  difTereutial  diagnosis  between  measles  and  small-pox 
has  already  been  considered.  There  will  certainly  lie  no 
difficulty  in  making  a  diagnosis,  if  you  wait  until  the  third 
day  of  the  eruption ;  then  the  small-pox  vesicle  is  formed. 
The  same  is  true  of  varicella  and  other  vesicular  diseases. 

The  eruption  of  measles  differs  from  that  of  roseola.  In 
measles  it  is  partially  confluent,  in  roseola  it  is  non-contlu- 
ent.  In  roseola  the  mucous  membrane  of  the  fauces  is  not 
intensely  injected.  In  measles  the  fever  runs  a  characteris- 
tic course.  If  the  temperature  is  normal,  if  the  eruption  on 
the  trunk  is  of  a  bright  red  color,  if  the  surface  is  smooth, 
and  if  catarrhal  symptoms  are  absent,  you  may  exclude 
measles.  The  non-contagious  charact<n-  of  roseola  is  an  im- 
])ortant  element  of  differential  diagnosis. 

It  is  hardly  possible  to  mistake  syphilitic  exanthemata 
for  measles,  for  there  are  certain  glandular  changes  which 
attend  the  development  of  syi)hilitic  erui)tions  which  estab- 
lish the  diagnosis.  In  the  early  period  of  the  disease,  when 
coryza  is  a  prominent  symi)tom,  before  the  ap]>earance  of 
the  eruption,  measles  may  l.)e  mistaken  for  an  ordinary  in- 
fluenza. 

PiioGXOSis. — The  prognosis  in  uncom]>licated  meash's  is 
always  good.  Any  irregularity  in  its  dev.'h)iiment,  and 
dentition  in  children,  may  render  the  prognosis  unfavora- 
ble.    In  the  hemorrhagic,  in  the  ulcerative,  and  in  the  ty- 


350  MEASLES. 

phoid  variety,  or  black  measles,  as  it  is  termed,  the  prog- 
nosis is  grave.  Measles  occurring  in  pregnancy  almost 
invariably'  prove  fatal. 

Ill  severe  cases,  the  deviations  from  the  typical  course  of 
the  disease  which  render  the  prognosis  unfavorable  are  a 
temperature  of  105°  F.  or  106°  F.,  during  the  period  of  ini- 
tiatory fever,  a  retardation  or  an  irregular! tj^  in  the  appear- 
ance of  the  eruption  at  the  beginning  of  the  eruptive  stage, 
and  the  occurrence  of  complications,  especially  broncho- 
pneumonia, croupous  laryngitis,  and  diphtheria. 

Profuse  hemorrhages  from  the  mucous  surfaces  during 
any  period  of  the  fever,  render  the  prognosis  unfavorable. 

The  hygienic  surroundings  of  the  patient  greatly  influence 
the  prognosis. 

The  prognosis  also  depends  upon  the  age  of  the  patient ; 
the  rate  of  mortality  is  much  greater  among  adults  than 
children.  The  character  of  the  prevailing  epidemic  deter- 
mines to  a  very  great  degree  the  prognosis. 

When  measles  is  developed  in  one  who  is  suffering  from 
a  severe  chronic  disease,  especially  some  organic  disease  of 
the  lungs,  the  prognosis  is  unfavorable.  The  patient  will 
not  probably  die  during  the  active  period  of  the  measles, 
but  the  chronic  pulmonary  disease  may  terminate  fatally 
from  the  effect  produced  by  the  sequelae  of  measles.  For 
instance,  a  person  has  evidences  of  consolidation  about  the 
apex  of  the  lung,  a  condition  which  justifies  a  favorable 
prognosis ;  let  measles  be  developed  in  this  same  person, 
and  capillary  bronchitis,  terminating  in  a  more  or  less  ex- 
tensive pneumonia,  will  probably  occur,  from  which  acute 
phthisis  may  be  developed. 

In  measles,  death  rarely  occurs  during  the  first  w^eek  of 
the  disease  ;  it  usually  takes  place  during  the  second  week  ; 
if  serious  complications  occur,  it  may  take  place  later  in 
the  disease. 

TiiEATMEisTT, — The  prophylactic  treatment  of  measles  con- 
sists in  isolating  the  affected  person. 

When  the  disease  runs  its  regular  course,  the  principal 
duty  of  the  physician  is  to  watch  for  and  guard  against  the 
occurrence  of  pulmonary  complications.     As  regards  treat- 


TnKATMKNT.  :?."!l 

moTif,  all  tliat  is  necessary  is  to  place  the  paticul  in  a  larLj*', 
well-vciitilatt'd  room,  with  the  t<'m])<'ratun' of  (;:{  V.  or  (').")' 
F.  Tin'  (lift  should  I)''  milk.  Tln'  room  should  bf  dark»'in'd, 
so  tliat  the  coiigest<'(l  conjuucllx  ;r  may  not  Ix*  exposed  to 
light.  If  tlu'  patient  comiilains  of  itchinLi:  and  huininL;  of 
tlie  surface,  he  maybe  frt'(|U"'ntly  s])om;t'd  with  b'pid  watri-, 
this  causes  an  alleviation  of  tin-  itching  and  buining,  and 
reduces  the  tem]ierature.  In  an  ordinary  case  this  is  all 
that  will  bt?  required.  Hot  drinks  or  stimulants  have  no 
power  to  liasten  the  a))pearanc<'  of  the  eruption;  the  admin- 
istration of  the  latter  may  be  followed  by  very  injuri<»u3 
results  ;  convulsions  ma^'  occur  and  death  ensue. 

In  an  ordinary  case,  stimulants  should  never  be  adminis- 
tered during  the  initiatory  i)eriod  of  the  fever,  unless  there 
is  some  special  indication  for  their  use,  such  as  gn'at  pros- 
tration, or  bronchial  complication  ;  then  they  may  sometimes 
be  used  with  benefit.  Covering  the  patient  with  heavy 
clothing  does  not  hasten  the  appearance  of  the  eruption. 

The  greatest  cleanliness  should  be  observed  ;  besides, 
there  should  be  free  ventilation,  avoiding  all  draughts  in 
the  sick-room.  If  there  is  thirst,  cold  water  may  be  freely 
taken  in  small  quantities  at  a  time. 

If  the  case  is  severe,  and  the  temperature  rises  to  103°  F.  or 
J 04°  F.,  it  may  be  reduced  by  fn.'qiiently  sponging  the  sur- 
face with  tepid  or  cold  water.  German  writers  recommend 
the  cold  batli  in  the  treatment  of  measles.  I  should  hesitate 
to  place  a  ])atient  with  measles  in  a  cold  bath,  on  account 
of  the  great  tendency  in  this  disease  to  pulmonary  complica- 
tions. 

Only  a  few  days  since  I  saw  a  child  sick  with  measles, 
who  had  been  treated  with  cold  baths  for  the  reduction  of 
tempei-ature.  I  found  the  physical  evidences  of  extensive 
lobular  pneumonias,  which  the  attending  physician  said 
had  l)e»'n  developed  within  the  previous  twenty-four  hours, 
so  that  there  was  little  doubt  l)ut  that  the\'  were  developed 
subsequent  to  the  baths. 

My  own  experience  leads  me  in  the  treatment  of  measles 
to  employ  quinine  as  an  antipyretic,  in  preference  to  cold 
to  the  surface,  either  by  baths  or  ])a(ks. 


352  MEASLES. 

You  will  recollect  I  stated  that  tlie  post-pliaiyngeal 
catarrh  is  liable  to  extend  into  the  larynx  and  bronchial 
tubes  and  give  rise  to  bronchitis.  One  of  the  most  impor- 
tant duties  of  the  pli3'sician  is  to  watch  for  the  occurrence 
of  this  complication  ;  he  should  frequently  examine  the 
chest,  and  wlien  the  bronchitis  is  found  to  have  reached  the 
capillaiy  tubes,  should  immediatly  commence  treatment  for 
its  relief.  I  have  found  the  inhalation  of  steam  to  afford 
the  greatest  relief  and  best  control  the  bronchial  inflamma- 
tion. As  soon  as  I  find  that  the  larynx  has  become  so  in- 
volved as  to  interfere  w^itli  the  respiration  of  the  patient, 
and  there  is  danger  of  croupous  laryngitis,  I  immediately 
order  vaj)or  inhalations  and  insist  upon  their  continuance 
until  the  laryngeal  symptoms  shall  have  subsided.  Some- 
times this  subsidence  will  take  place  within  two  or  three 
hours,  and,  again,  not  until  after  two  or  three  days.  I  de- 
sire to  impress  upon  you  the  value  of  vapor  inhalations  in 
the  treatment  of  the  laryngeal  and  bronchial  complications 
of  measles.     I  have  come  to  regard  them  as  of  great  value. 

When  catarrhal  pneumonia  is  developed  it  is  to  be  treated 
in  the  same  manner  as  catarrhal  pneumonia  developed  un- 
der any  other  circumstances ;  the  patient  should  be  sustained 
by  the  free  use  of  stimulants. 

Pulmonary  complications  in  measles  are  often  the  result 
of  exposure  to  sudden  changes  in  temperature ;  the  severity 
of  catarrhal  symptoms  will  alwaj^s  be  increased  by  such  ex- 
posure, therefore  it  is  of  great  importance  in  the  manage- 
ment of  a  case  of  any  type  of  measles  that  the  patient  should 
be  protected  against  such  exposure. 

When  there  is  great  restlessness  during  the  fever  of  in- 
vasion, or  during  the  early  period  of  the  eruptive  stage, 
small  doses  of  opium,  in  the  form  of  Dover's  powder,  may 
be  administered  with  marked  benefit. 

The  management  of  the  different  varieties  of  measles  will 
be  indicated  by  the  general  condition  of  the  patient.  In 
the  ulcerative,  hemorrhagic,  and  typhoid  varieties,  the  free 
administration  of  stimulants  should  be  early  commenced. 
Usually  in  these  varieties  there  is  great  prostration,  and  the 
thing  to  be  accomplished  is  the  support  of  your  patient. 


OKiniAN'    MKASI.KS. — MoKlUD    AXAToMY.  '.l^u^ 

GiKMAN  Mi;a>ij>,  or  HjntJeinic  Roseola. — Before  leiiviii'; 
the  subject  of  inetislt's  I  will  call  your  aftcution  to  an  alTcc- 
tion  which  has  recently  received  the  name  of  (IrniKin 
measles.  It  is  C()niim»nly  known  liy  llie  term  ro.^tula.  or 
mock  iiirash's.  It  has  Ijecn  reii;anle(l  by  some  as  a  inodilied 
form  of  measles;  by  others  as  a  niodilied  form  of  scarh-f 
fever;  again  it  has  been  thought  to  be  a  combination  of  th«' 
two  diseases. 

Some  writers  maintain  thai  we  are  not  justilit-d  in  calling 
this  type  of  measles  an  independent  and  specific  disease, 
but  that  it  may  endjiace  any  blotchy  exanthemata,  from  the 
appearance  of  which  we  are  unable  to  determine  what  we 
shall  call  the  disease ;  whether  scarlet  fever,  or  measles,  or 
urticaria,  etc. 

Later  German  writers  regard  it  as  an  indejx.'iuh'nt  all'ec- 
tion,  a  specific,  acute,  and  contagious  eruptive  fever,  and 
have  given  to  it  the  name  of  rubeola. 

I  am  disposed  to  regard  it  only  as  a  different  tyix.*  of 
measles  from  that  which  ordinarily  prevails,  and  by  way  of 
distinction  will  call  it  German  measles.,  ov  epidemic  roseola. 

MoKBiD  Anatomy. — This  affection  must  be  regarded  as 
one  of  the  mildest  of  eruptive  fevers.  It  lias  prevailed  epi- 
demically and  endemically.  The  study  of  its  morbid  anat- 
omy has  been  almost  exclusively  restricted  to  the  eruption. 
This  is  an  exanthemata  consisting  of  irregular  spots,  orhy- 
persemic  blotches,  varying  in  size  from  a  pin's  head  to  a 
large  pea,  usually  slightly  elevated,  so  that  when  i\\o  hand 
passes  over  them  the  surface  of  the  skin  feels  somewhat 
rough.  Sometimes  these  spots  occasion  intense  itching; 
they  are  (juite  distinctly  separated  by  healthy  skin,  and 
disappear  under  pressure.  As  a  rule,  even  at  the  acme  of 
the  development  of  the  eruption,  their  color  is  a  ''  jiale  rose 
red,"  paler  than  the  intense  red  of  the  erui)tion  of  scarlet 
fever,  or  the  peculiar  bluish  hue  of  the  eru])tion  in  sev«»re 
cases  of  measles.  The  eruption  can  readily  l)e  recognized. 
It  is  seen  upon  all  parts  of  the  body,  but  is  most  abundant 
upon  the  face  and  trunk.  The  spots  are  usually  discrete  ; 
they  often  lie  crowded  closely  together,  but  they  are  not 
confluent, 

23 


354  MEASLES. 

The  eruption  is  exceedingly  fugitive,  rarely  remaining 
visible  more  than  twenty -four  or  forty-eight  hours.  It  may 
continue  visible  for  three  or  four  days.  The  period  of  its 
most  marked  development  may  be  only  a  few  hours — twelve 
hours  is  the  limit.  In  some  cases  there  is  slight  desquama- 
tion ;  in  most  cases  the  eruption  disappears,  and  leaves  no 
trace,  except  in  occasional  instances,  when  there  is  a  tran- 
sient and  yellowish  discoloration  of  the  skin.  Some  writers 
affirm  that  the  eruption  may  disappear  and  reappear  alter- 
nately for  several  days,  and  when  it  has  finally  disappeared 
the  disease  has  terminated,  and  there  is  nothing  to  fear 
from  complications  or  sequelse.  In  certain  rare  cases  vesi- 
cles resembling  miliaria  may  be  developed  upon  the  hyper- 
?emic  spots,  especially  upon  the  back  ;  doubtless  these  are 
chiefly  due  to  external  conditions. 

Etiology. — Doubtless  this  disease  is  a  contagious  affec- 
tion. Nothing  is  known  concerning  the  nature  of  its  con- 
tagion. It  is  essentially  a  disease  of  childhood.  In  persons 
more  than  forty  years  of  age  its  development  is  of  very  rare 
occurrence.  It  is  conveyed  from  one  person  to  another  in 
the  same  manner  as  measles.  It  has  been  thought  by  some 
that  women  were  more  susceptible  than  men  to  the  influ- 
ence of  the  contagion,  and  that  high  atmospheric  tempera- 
ture has  a  great  influence  in  its  development. 

Symptoms. — Epidemic  roseola  is  so  mild  an  affection, 
that  it  is  questionable  whether  it  has  an  invasive  stage. 
The  duration  of  the  stage  of  incubation  has  not  been  deter- 
mined. Generally,  the  symptoms  which  manifest  them- 
selves two  or  three  days  before  the  appearance  of  the  erup- 
tion are  much  less  marked  than  they  are  in  any  other 
eruptive  fever.  Perhaps  in  many  cases  they  escape  notice. 
Quite  frequently  the  eruption  is  the  first  symptom  of  the 
disease.  In  some  cases  there  may  be  nothing  more  than  a 
feeling  of  discomfort.  In  other  cases  the  disease  may  be 
ushered  in  by  vomiting,  diarrhoea,  and  convulsions.  In 
many  cases,  immediately^  preceding  the  eruption,  and 
accompanying  its  appearance,  there  is  well-marked  fever^ 
headache,  loss  of  appetite,  and  sometimes  noticeable  pros- 
tration.    When  the  eruption  is  regular  in  its  appearance 


SYMPTOMS.  :V)r> 

it  MiT.-cts  first  til.'  facr  imd  scmIj),  ih.-n  <:i:i(lii;illy  ••xt.-iids 
downward  over  tlif  trunk  and  rxircniilirs.  I'snally,  the 
dt'Vflopinent  and  s))t'cd  of  tlir  ciuiytion  is  ra])id,  ])rrliai»s 
no  more  tlian  two  or  three  days  beini?  occMijiied  in  its 
l)assa<;(' ov(M- the  entin^  body.  Its  duiation  ui)on  anyone 
part  of  tli.>  body  before  it  be^jins  to  disa].i)rar  is  not  more 
than  from  twelve  to  twentj^-four  hours.  Within  forty-ci-^lit 
hours  it  lias  almost  entirely  disajipeared.  In  the  majority 
of  cases  the  temp«>ratnre  does  not  rise  more  than  lOOA^  F. 
to  101^°  F.  above  the  normal  standard.  It  may  rise  from 
102°  F.  to  104  F.°  During  the  second  day  of  the  disease 
the  temperature  begins  to  fall.  Sometimes  it  reachos  the 
normal  standard  within  twelvt^  hours,  occasionally  not 
nntil  the  third  day.  Sometimes  it  reaches  it  by  crisis,  at 
other  times  by  gradual  descent. 

The  i)ulse  increases  and  diminishes  in  frequency  accord- 
ing to  the  rise  and  fall  of  temperature. 

The  tongue  is  usually  covered  with  a  whitish  coating,  is 
dotted  here  and  there  with  red  and  swollen  i)apilhe.  The 
mucous  membrane  of  the  fauces  is  generally  congested,  and 
the  tonsils  moderately  swollen  ;  there  may  be  some  soreness 
of  the  throat. 

The  mucous  membrane  of  the  air-passages  is  usually 
in  a  condition  of  mild  catarrh,  consequently  at  the  onset 
of  the  disease  sneezing  and  coughing  are  frequently  pres- 
ent, ]>ut  they  are  less  marked  and  are  of  shorter  duration 
than  in  the  ordinary  t^^pe  of  true  measles. 

Suifusion  of  the  e^-es  with  congestion  of  the  conjunctival 
vessels  is  rarely  present  ;  there  maybe  a  slight  degree  of 
photo])liobia.  The  face  and  e3'elids  are  usually  slightly 
swollen  at  the  time  the  eruption  makes  its  appearance,  but 
this  swelling  rapidly  disappears. 

In  most  cases,  there  is  moderate  swelling  of  the  lymphatic 
glands  of  the  neck,  and  enlargement  of  the  glands  at  the 
nape  of  the  neck.  Moderate  enlargement  of  the  occipital 
glands  may  continue  for  a  number  of  days.  Sup])urafion 
of  lymphatic  glands  has  not  been  observed.  The  urine  is 
usually  normal  ;  it  may,  however,  contain  an  abnormal 
amount  of  the  chlorides. 


356  MEASLES. 

You  liave  already  learned  tlie  fact,  that  wlien  this  dis- 
ease runs  its  regular  course,  it  is  exceedingly  mild  in  char- 
acter. So  mild,  that  children  generally  dislike  to  remain 
in  bed,  and  prefer  to  be  out-of-doors  and  at  play. 

Differential  Diagnosis.— One  of  the  prominent  fea- 
tures of  this  disease  is  the  close  resemblance  which  its 
eruption  bears  to  that  of  measles.  In  certain  cases  it  may 
be  impossible  by  the  eruption  alone  to  make  a  differential 
diagnosis.  When  the  eruption  of  measles  is  not  typically 
developed,  a  complete  history  of  the  case  must  be  taken 
into  consideration.  When  this  has  been  done,  usually 
there  is  no  great  difficulty  in  arriving  at  a  correct  diagnosis. 
Perhaps,  that  which  will  best  aid  you  in  making  a  dif- 
ferential diagnosis  between  roseola  and  measles  is  the  fact 
that  an  attack  of  one  does  not  protect  against  the  other, 
any  more  than  does  an  attack  of  varicella  protect  an  indi- 
vidual from  an  attack  of  variola.  This  fact  certainly 
establishes  the  non-identity  of  the  two  diseases. 

It  has  been  questioned  whether  a  person  may  not  have  a 
second  attack  of  epidemic  roseola.  The  latest  observations 
go  to  prove  that  a  second  attack  of  roseola  is  of  as  rare 
occurrence  as  a  second  attack  of  measles  or  scarlet  fever. 
Again,  the  evidence  seems  most  conclusive  that  an  attack 
of  this  disease  does  not  protect  an  individual  against  the 
contagion  of  scarlet  fever;  nor  does  an  attack  of  scarlet 
fever  protect  one  against  the  contagion  of  roseola.  An  in- 
dividual may  have  an  attack  of  German  measles  very  soon 
after  he  has  been  ill  with  measles  or  scarlet  fever. 

Prognosis. — The  prognosis  is  always  good.  Complica- 
tions rarely  occur.  When  they  do,  they  are  usually  pul- 
monary affections. 

Treatment. — The  treatment  of  this  affection  simply  con- 
sists in  protection  against  exposure.  Tepid  sponging  will 
relieve  troublesome  itching,  and  reduce  fever.  Regulate 
the  diet,  and  carefully  watch  the  catarrh  of  the  air-pas- 
sages. In  some  cases,  a  mild  course  of  tonic  treatment 
may  be  beneficial.  As  a  rule,  convalescence  is  rapid,  and 
is  completed  without  hindrance. 


MORBID    AN'AT(»MV.  357 


MILIARY  FEVER. 


Tliis  form  of  fever  c;iniu)l  strictly  be  ref^arded  as  a  coii- 
tui^ious  disease,  but  it  so  frtH[iit'ntly  i)revails  in  (ujiinection 
with  measles  and  scarlet  fever,  and  lias  a})i)arently  so  many 
elements  of  contagion,  tliat  1  lia\  •■  inchub'd  it  in  tlif  list  of 
contagious  fevers. 

Some  deny  its  existence  as  a  distinct  fever.  \Vi  it.  is  have 
described  it  under  the  names  of  auflontina,  stKhtnd  cx(in- 
t/icma,  miliaria  alba,  etc.  I  shall  adopt  the  name  of  miliary 
fever. 

Several  diseases  which  are  accompanied  by  sweating, 
and  which  exhibit  a  tendency  to  the  formation  of  miliary 
vesicles,  have  been  called  miliary  fever.  L'ntil  the  occur- 
rence t>f  the  severe  ei)idemic  of  the  disease  known  as  the 
"English  Sweating  Sickness,"  its  specific  type  was  not  rec- 
ognized. It  luis  prevailed  epidemically  over  limited  areas, 
in  Belgium,  France,  England,  Germany,  Italy,  and  Austria. 

In  some  of  these  epidemics  one-fifth  to  one-tenth  i)er  cent, 
of  the  whole  population  of  the  invaded  district  has  been  at- 
tacked by  the  disease.  The  average  duration  of  the  epi- 
demics has  been  from  three  to  four  weeks,  occasionally  they 
have  lasted  from  three  to  four  montlis. 

MoKHin  Anatomy. — Few  j)ost-mortem  examinations  have 
been  made,  and  those  few  have  failed  to  reveal  any  charac- 
teristic lesion. 

During  life  the  blood  is  thin,  of  a  l)right-red  color,  and 
coagulates  imperfectly  ;  after  death  it  is  thin  and  dark- 
colored. 

Generally,  the  internal  organs  present  evidences  of  hyper- 
jomia.  The  mucous  membrane  of  the  air- passages  is  red 
and  frequently  covered  with  reddish  mucus.  The  lungs 
and  liver  are  generally  filled  with  blood  ;  th(»  latter  is  soft«'r 
than  normal.  The  spleen  is  always  enlarged  and  soft. 
Some  observers  have  reported  the  kidneys  to  be  in  a  normal 
condition  ;  other  observers  have  reported  them  to  be  in  a 
condition  of  congestion.  The  mucous  membrane  of  the 
stomach  and  intestines  is  usually  re(lden»'d,  and  presents 
here  and  there  red  spots.      Occasionally  these  spots  are  very 


358  MILIAEY  FEVEE. 

numerous,  and  vesicles  are  sometimes  seen  in  the  small  in- 
testines. By  some  these  vesicles  have  been  supposed  to  be 
swollen,  solitary  follicles  ;  by  others  they  have  been  thought 
to  be  distinct  miliary  vesicles,  similar  to  those  which  are 
seen  upon  the  surface  of  the  body.  Superficial  ulcers  are 
sometimes  seen,  especially  in  the  region  of  the  ilio-csecal 
valve. 

The  miliary  vesicles  which  are  seen  upon  the  surface 
of  the  body,  and  the  cutaneous  eruption,  are  developed 
because  the  secretion  of  the  sudoriferous  glands  cannot 
escape. 

The  escape  of  the  contents  of  these  glands  may  not 
take  place  for  two  reasons  :  First,  the  gland-ducts  may 
become  obstructed.  Second,  the  secretion  may  be  so  abun- 
dant that  it  cannot  be  transmitted  by  the  gland-duct. 

In  either  case,  the  secretion  emerges  under  the  epidermis 
around  the  sweat-duct,  and,  as  the  scales  are  lifted  uid,  a 
small  clear  vesicle  is  formed.  The  liquid  contained  in  the 
vesicle  at  first  is  transparent,  has  an  acid  reaction,  and  is 
said  to  contain  free  nuclei-cells,  which  have  three  or  more 
nuclei ;  these  nuclei  remain  visible  after  the  cell  membrane 
has  been  destroyed  by  the  addition  of  acetic  acid. 

It  has  been  claimed  that  the  virus  of  the  disease  is  con- 
tained in  these  polynucleated  cells.  After  death,  the  skin 
becomes  oedematous,  and  very  soon  the  odor  of  decomposi- 
tion is  perceivable. 

Etiology. ^ — It  was  formerly  supposed  that  miliary  fever 
was  indirectly  induced  by  scarlatina,  the  puerperal  con- 
dition, variola,  vaccinia,  typhus  fever,  and  other  diseases, 
and  that  it  was  not  a  distinct  disease  arising  from  some 
constitutional  cause.  The  prevalence  of  this  fever  in  con- 
nection with  these  diseases  gave  rise  to  this  supposition. 

Epidemics  of  this  disease  have  generally  prevailed  during 
the  spring  and  summer  months ;  from  this  fact  one  would 
be  led  to  think  that  there  is  some  atmospheric  condition 
peculiar  to  these  months.  Again,  the  disease  has  most  fre- 
quently appeared  in  warm,  moist  weather,  and  from  this 
fact  it  has  been  supposed  that  some  peculiar  condition  of 
the  soil  is  necessary  to  its  development.     Certain  epidemics 


ETIOLi)(;V.  359 

Imvt'  sliowii  a  close  connection  uiili  coiifaminations  of  the 
soil,  such  as  arise  from  nc^lfct  of  «lraina^<',  collections  of 
refuse,  etc.  Doubtless,  such  coiKlitions  of  the  soil  may  in- 
crease its  severily,  iiml  cause  ii  lo  prevail  more  extensively, 
but  facts  do  not  jJiove  tliiit,  direcily  oi-  iiKlirtM-tl}',  thi-y 
cause  its  (leveloiuu<'nt. 

The  (lis.-ase  u-iially  :ii lacks  healfliy  adults,  and  occurs 
more  freiiuently  amoni;  females  than  males.  It  attacks  all 
classes,  and  its  spread  does  not  seem  to  be  affected  by 
crowding. 

It  can  hardly  b(^  regarded  as  a  contagious  disease,  in  tiie 
sense  that  it  can  be  communicated  directly  from  tiie  sick  to 
the  well.  It  does  not  seem  to  be  well  established  that  the 
disease  can  be  develo])ed  by  inoculation  with  the  contents 
of  the  vesicle,  notwithstanding  it  has  been  supi)osed  that 
certain  cells  in  the  fluid  hold  the  contagion  of  the  disease. 

Theinfn^tiuenc}'  of  the  simultaneous  occurrence  of  miliary 
fever,  with  epidemics  of  measles  or  scarlet  fever,  is  unfavor- 
able to  the  theory  that  there  is  a  specific  relationship  be- 
tween the  poisons  of  these  diseases. 

The  view  that  there  is  an  intimate  relationshi})  between 
cholera  and  miliary  fever  has  been  accepted  by  some  wri- 
ters, and  the  accession  of  the  latter  during  the  course  of 
the  former  has  been  supposed  to  exert  a  lavorai)le  influence 
over  the  course  of  the  disease  ;  the  opposite,  however,  does 
not  appear  to  hold  good,  but,  on  the  contrary,  favors  a 
fatal  termination.  Much  remains  to  be  learned  in  regard 
to  the  relationship  existing  between  miliary  fever  and  the 
other  diseases  which  we  have  mentioned. 

The  etiology  seems  to  be  mainly  speculative  and  theo- 
retical. 

Symptoms, — The  average  dumtion  of  the  disease  is  from 
five  to  eight  days. 

It  has  three  stages  :  First,  ///c  .vA///t  o/"  inrasi<ni  ;  second, 
the  stage  of  sweat liuj  ;  third,  the  stage  of  eruption  mid  <hs- 
qtiamation. 

Till'  stage  of  Invasion. — The  average  duration  of  this 
stage  is  from  forty-eight  to  seventy-two  hours.  It  is  char- 
acterized bv  an  excessive  irritati«»n  of  the  skin,  thirst,  gen- 


360  MILIARY   FEVER. 

eral  lassitude  and  headache.     There  is  also  more  or  less 
febrile  movement. 

Some  writers  mention  a  feeling  of  suffocation,  which  is 
usually  preceded  by  a  sense  of  oppression  at  the  epigas- 
trium. These  are  the  characteristic  symptoms  of  the  stage 
of  invasion. 

The  stage  of  sioeatlng. — This  stage  is  usually  ushered  in 
b}^  rigors  ;  rarely,  by  a  well-marked  chill.  The  character- 
istic symptom  of  this  stage  is  profuse  and  persistent  sweat- 
ing. The  sweating  is  accompanied  by  a  prickling  sensation 
of  the  skin,  distress,  and  a  sense  of  compression  at  the  epi- 
gastrium, by  more  or  less  violent  paljDitation  of  the  heart, 
with  precordial  pain.  Usually  the  sweat  appears  on  all 
parts  of  the  body  at  the  same  time.  Sometimes  it  appears 
first  upon  the  head  and  breast,  then  gradually  descends, 
and  soon  becomes  so  abundant  that  every  article  of  cloth- 
ing, bed-clothes,  and  bedding,  becomes  saturated. 

The  pulse  sometimes  reaches  140  beats  per  minute,  the 
temperature  rises  to  103°  F.,  104°  F.,  or  105°  F.,  and  the 
skin,  notwithstanding  the  profuse  perspiration,  feels  ex- 
tremely hot. 

During  this  stage  the  headache  and  the  sense  of  suffoca- 
tion increase,  the  epigastric  and  precordial  pain,  and  the 
palj^itation  increase  in  severity,  and  sometimes  become 
alarming,  although  the  most  careful  physical  examination 
fails  to  discover  any  lesion  in  the  heart  or  lungs  to  account 
for  them.  The  respiration  becomes  rapid,  often  irregular 
and  intermittent.  Irregular  exacerbations,  or  even  inter- 
missions, in  these  symptoms  may  occur,  but,  as  a  rule,  they 
continue  without  abatement  until  the  vesicle  appears  on 
the  third  or  fourth  day  of  the  disease. 

The  Stage  of  Eruption. — This  stage  is  characterized 
by  the  appearance  of  a  rash.  It  is  first  seen  upon  the  neck 
and  breast,  then  upon  the  back  and  extremities,  sometimes 
upon  the  mucous  membrane  of  the  mouth,  nose,  and  con- 
junctiva, sometimes  upon  the  abdomen  and  scalp.  This  erup- 
tion consists  of  irregularly  shaped  spots,  thre<^  or  four  mm. 
in  diameter.  In  some  cases  they  stud  the  skin  so  thickly 
that  it  appears  like  an  uniform  sheet  of  vivid  redness. 


SYMPTOMS.  361 

After  the  lapse  of  a  few  liours,  vesicles  ran  be  s^mti  in  the 
centre  of  these  spots  ;  ])('rlia})s,  at  first,  they  are  so  small  as 
to  necessitate  the  aid  of  a  Irns  to  discover  them.  These 
vesicles  rapidly  increase  in  size,  and  may  reach  the  size  of  a 
millet-seed  or  a  small  ])ea.  T\w  contents  of  these  vesicles 
have  already  been  described. 

Occasionally,  as  the  eru])tion  appears,  all  the  constitu- 
tional symjjtoms  are  increased  in  severity,  ]»iit,  usually,  they 
art'  uiodilit'd  and  ilisa])}ii'ar  cither  suihh'idy  oi*  gradually 
aftrr  its  development.  In  the  luilder  cases  the  vesicles 
only,  without  the  efllorescence,  are  seen. 

X'omiling  is  rarely  present,  although  nausea  is  a  com- 
mon symptom,  as  is  also  constipation.  The  urine  is  usually 
scanty  and  high  colored  ;  in  some  cases  there  is  su]ipression 
of  urine.  Occasionally,  during  tiie  stage  of  eruption,  pro- 
fuse secretion  of  urine  takes  place.  This  has  been  regarded 
as  a  favorabh^  symptom. 

The  vesicles,  clear  at  first,  soon  become  opaque  and  yel- 
lowish, continue  for  two  or  three  days,  then  burst  and  begin 
to  fall  off  in  scales.  Desquamation  is  usually  com])Ieted 
within  forty-eight  hours,  but  convalescence  is  often  quite 
protracted  on  account  of  the  debility  and  emaciation. 
Such  is  a  brief  description  of  miliary  fever,  when  it  runs  a 
regular  course,  but  there  are  certain  variations  in  the  de- 
velopment of  the  symptoms  which  should  be  noticed.  In 
the  severest  form  of  the  disease,  the  tenqx^rature  may  rise 
to  107'  or  108°  F.,  and  there  ma}'  be  a  sense  of  suffocation  and 
raging  delirium.  Again,  there  may  be  absence  of  the  erup- 
tion, sweating,  and  convulsions  followed  by  death.  Occasion- 
ally sudden  and  fatal  colla}»se  follows  the  sweating  stage. 

The  typhoid  condition  may  be  developed  in  the  sweating 
stage,  and  may  be  attended  In*  black  sordes  U])on  the  teeth 
and  tongue,  ejiistaxis  and  uterine  hemorrhage,  and  may 
terminate  in  death,  without  any  considerable  anatomical 
changes  recognizable  after  death. 

Co?7t plica/ ions  are  not  of  frequent  occurience.  Occasion- 
ally there  is  bronchitis,  jineumonia,  and  angina. 

Rrhipsr.s  are  of  common  occurrence,  but  recovery  gener- 
ally takes  place  after  a  short  relapse. 


362  MILIAPwY  FEVER. 

Differential  Diagnosis. — Miliary  fever  ma}^  be  con- 
founded witli  measles,  with  tj^plioid  fever,  and  with  dengue 
fever.  The  profuse  sweating,  the  x^rickling  of  the  skin,  the 
intense  ojipression  at  the  epigastrium,  the  sense  of  suffoca- 
tion, with  precordial  pain,  and  the  peculiarity  of  the  erup- 
tion, are  sufficient  to  distinguish  it  from  measles,  from 
intermittent  fever  (although  a  decidedly  intermittent  type 
of  the  disease  sometimes  prevails),  and  from  typhoid  fever. 
When  the  disease  prevails  epidemically,  the  diagnosis 
cannot  be  difficult. 

Prognosis. — When  the  disease  runs  a  regular  course, 
with  only  a  moderate  degree  of  severity,  the  prognosis 
is  good ;  whereas,  great  severity  of  the  febrile  symptoms, 
exceptionally  profuse  sweating,  and  increasing  sense  of  con- 
striction of  the  chest,  with  suffocation,  render  the  prognosis 
unfavorable.  The  accession  of  profuse  hemorrhages,  coma, 
convulsions,  active  delirium,  or  symptoms  of  collapse,  ren- 
der the  prognosis  unfavorable. 

The  severity  of  the  symptoms  is  usually  mitigated  when 
the  eruption  makes  its  appearance,  and  death  rarely  occurs 
after  that  stage  is  reached.  If  fatal  termination  is  reached, 
it  usually  takes  place  during  an  exacerbation,  prior  to  the 
appearance  of  the  eruption. 

In  some  epidemics,  the  mortality  has  been  very  great ;  in 
other  epidemics  the  disease  has  been  mild  in  character. 
The  character  of  the  epidemic  affects  the  prognosis. 
Treatment. — At  one  time  diaphoretics  were  employed 
in  the  treatment  of  this  disease,  on  the  supposition  that 
the  sweating  and  eruption  were  critical  manifestations,  and 
must  be  aided  by  all  possible  means. 

The  sense  of  suffocation,  with  that  of  constriction  of  the 
chest,  was  thought  to  indicate  blood-letting  ;  but  it  was 
soon  decided  that  loss  of  blood  aggravated  rather  than  im- 
proved the  patient's  condition. 

Antispasmodics,  nervines,  quinine,  emetics,  and  counter- 
irritants,  at  different  times  have  formed  the  basis  of  various 
plans  of  treatment.  Of  late,  subcutaneous  injections  of 
morphine  have  been  used  with  advantage.  Sinapisms  and 
blisters  have  been  employed  for  the  relief  of  the  sense  of 


TREATMKXT.  'MVA 

constriction  in  llu'  rlicst,  mid  fur  the  <'])igastri(:  tiiid  iiivror- 
(lial  (lisfros,  with  lifndii  to  lli«'  jKitimt. 

It  is  now  ackii()\vlt'(li;t'<l  tlint  tlic  Mdniiiiistiatioii  of  inir^ii- 
lives  ill  large  doses  siiouM  In-  caicrully  avoidrd,  as  wdl  as 
I'loodk'tting,  general  uv  local. 

At  ])resent  the  expectant  ]»IaM  of  tivat  iiiiiil  is  regarded 
with  most  I'avor.  It  chietly  consists  in  ihi-  use  of  cooling 
iliinks,  aromatic  teas,  acidulated  water,  sponging  with 
warm  water,  or  the  em])loyment  of  wai-ni  baths.  It  lias 
been  thought  that  the  addition  of  alum  or  vim-gar  to  the 
water  used  Tor  s})onging  or  bathing  is  benelicial. 

In  tlie  treatment  of  this  alTection,  ([iiinine  seems  to  be 
regarded  with  almost  universal  favor.  If  restlessness  is 
persistent,  t)i)iuni,  ether,  and  antis])asmodics  may  ha  em- 
ployed in  moderate  doses,  carefully  watching  tlie  effect 
produced.  Tlie  ]Kitient  should  be  surrounded  by  proi)er 
hygienic  intluences,  his  diet  should  l)e  moderately  nutritive, 
and,  in  those  cases  in  which  convalescence  is  tedious,  a 
steady  and  continued  tonic  treatment  is  indicated. 

In  the  severest  form  of  the  disease  stimulants  may  be 
emploj-ed  with  benefit. 


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INDEX. 


PAOK 

Algid  variety  of  pernicious  fever 157,  158 

Alkalies  in  the  treatment  of  typhoid  fever 77 

Antipyretics  in  the  treatment  of  simple  remittent  fever 140-148 

"  "  "  typhoid  fever 00-73 

"  "  "  typho-malarial  fever l!»S-200 

Arrangement  of  sick-room  in  the  treatment  of  measles 351 

*'  "  "  simple  remittent  fever 140 

"  "  "  typhoid  fever 04 

"  "  "  typhus  fever 347 

Arthritic  pains  in  relapsing  fever 201 

Astringents  in  the  treatment  of  typhoid  fever 77 

Bibliography 365-384 

Bilions  remittent  fever 141 

Black  vomit  as  a  symptom  of  yellow  fever 90 

Blood,  changes  in  the,  in  measles 337 

"  "  miliary  fever 357 

•'  *'  pernicious  fever 149 

"  "  relapsing  fever 258 

♦'  "  simple  remittent  fever 132 

««  "  typhoid  fever 7,  8 

"  "  typho-malarial  fever 182 

"  "  typhns  fever 206 

"  "  yellow  fever 88 

Bloodletting  in  pemicions  fever 104 

"  typhoid  fever 03 

Brain,  changes  in  the,  in  pernicious  fever 151 

"  "  scarlet  fever 308 

"  •'  tyiihoid  fever 12 

*'  "  typhus  fever 207,  208 

"  "  yellow  fever 87 

Bronzed  liver  in  simple  remittent  fever 133 

Cathartics  in  the  treatment  of  dengue  fever 173 

•'  "  pemiciouH  fever , 1<54 

♦'  "  typhoid  fever 81 


386  ii^DEX. 

PAGE 

Chronic  malarial  infection 173-180 

"  "  definition  of 173 

««  «*  differential  diagnosis  of 177 

♦«  '«  etiology  of , 174 

««  "  morbid  anatomy  of 174 

«  "  "  "  heart 174 

"  "  "  "  liver 174 

ti  "  •   "  "  kidneys 174 

«  "  "  "  spleen 174 

"  "  prognosis  of 178 

«»  "  symptoms  of 174-177 

«  "  "  diarrhoea 175 

«  "  "  gastro- enteritis 175 

««  "  "  hemiplegia 175 

"  "  '«  hemorrhage 176 

"  "  "  hypochondriasis 176 

"  "  "  local  anaesthesia 175 

"  "  "  melancholia 176 

"  "  '•  neuralgia 176 

«'  "  treatment  of 179,180 

Citrate  of  iron  and  quinine  in  the  treatment  of  dengue  fever 173 

Cod-liver  oil  "  "  chronic  malarial  infection . .    179 

Colchicum  "  "  dengue  fever 172 

Cold  applications  "  "  measles 351 

"  *'  "  scarlet  fever 333 

"  "  "  simple  remittent  fever 148 

"  «'  "  typhoid  fever.. 67-70 

"  "  "  typho-malarial  fever 201 

'♦  "  "  typhus  fever 249 

Collapse  in  pernicious  tever 156 

Colliquative  variety  of  pernicious  fever 158 

Coma  vigil  in  typhus  fever 220 

Comatose  variety  of  pernicious  fever 153 

Contagion  in  measles "^^ 

"  relapsing  fever 260 

*'  scarlet  fever 308 

"  small-pox 273 

"  typhoid  fever 21 

"  typhus  fever 212-214 

"  yellow  fever 90-92 

Convulsions  in  pernicious  fever 155 

"  scarlet  fever 315 

"  typhoid  fever 37 

Delirious  variety  of  pernicious  fever 154,  155 

Delirium  in  pernicious  fever 15^ 

"  relapsing  fever 261 

"         scarlet  fever 312 


INDEX.  387 

PAoa 

Delirium  in  Btimll-pox 2''' 

tyi>hi)i(l  fcvor :t">--'''' 

*'  tyi>ho-nuvl!iiial  fovor "'«' 

"  typhus  fever 'J"20-J'Jw 

"  yellow  fever '^^ 

Dengue  fever Hi!)  17:? 

"  etiolopyof H>'J-170 

"  definition  of ^''•* 

"  differential  diagnosis  of . . .  .    ' '  ~ 

"  morbid  anatomy  of "•'•^ 

"  prognosis  of '  '*' 

"  symptoms  of '  '^'~'  '•' 

"  ''  enlargement  of  lymphatic  glands 170 

"  "  headache 1~0 

"  "  period  of  incubation 170 

««  "  pulse 1^*^ 

«'  "  skin 1~<^ 

•'  '  *  temperature 1 '  *^ 

»«  "  tongue I'l 

"  treatment  of 1 12.  li-? 

"  "  calomel  in  the 1 '  '•' 

«'  "  cathai-tics  in  the 1  ••' 

«»  ♦*  citrate  of  iron  and  quinine  in  the 1 '  -^ 

♦•  "  colchicum  in  the ^ '  - 

«»  "  diet  in  the l~-5 

«*  "  emetics  in  the ''3 

««  "  sulphate  of  quinine  in  the 1  <"J 

Diaphoretics  in  the  treatment  of  typhoid  fever I^-^ 

Diarrhcea  in  chronic  malarial  infection • '  •» 

"  relapsing  fever -  '^ 

"  typhoid  fever ''^ 

"  typho-malarial  fever 188-191 

Diet  in  dengue  fever ^  y' 

"      measles "■_J_ 

typhoid  fever ' 

"       tvpho  malarial  fever -  " 

"      typhus  fever ~'^^ 

Differential  diagnosis  of  chronic  malarial  infection ^  >' 

"  •'  dengue  fever ' '  ~ 

i«  "  epidfroic  roseola ''•'■* 

»»  •'  measles '*' - 

"  «'  miliary  fever •"'•'- 

♦»  »'  pernicious  fever 159-16w 

«4  "  relapsing  fever -'*■* 

"  "  scarlet  fever 32<>-3M 

•♦  «'  simple  intermittent  fever !-•> 

«  •;  simple  remittent  fever 1*'~.  l** 

«»  "  small-pox 2y4-288 


388  INDEX. 

PAGE 

Differeutial  diaguosis  of  typhoid  fever 45-49 

"  "  typho-malarial  fever 194-196 

"  "  typhus  fever 282-239 

"  "  yellow  fever 100 

Digitalis  in  the  treatment  of  typhus  fever 253 

Disinfectants  in  the  treatment  of  typhoid  fever 63 

Dry  cups  "  "  "  79 

Emaciation  in  typhoid  fever 38 

Emetics  in  the  treatment  of  dengue  fever 172 

"  "  pernicious  fever 164 

"  "  typhoid  fever 63 

Epidemic  roseola 353-356 

"  differential  diagnosis  of 354 

"  etiology  of 354 

"  morbid  anatomy  of 353 

"  prognosis  of 355 

"  symptoms  of 355,  356 

"  treatment  of 356 

Epistaxis  as  a  symptom  of  typhoid  fever 170 

Eruption  of  dengue  fever 169-171 

' '  epidemic  roseola 353 

"  measles 341 

"  miliary  fever 358-360 

' '  relapsing  fever 262 

"  scarlet  fever 313 

small-pox 270-273,  277-284 

"  typhoid  fever 42-43 

"  typhus  fever 219-225 

Etiology  of  chronic  malarial  infection 174 

"  dengue  fever 169, 170 

"  epidemic  roseola 354 

"  measles 339-341 

' '  miliary  fever 358,  359 

"  pernicious  fever 152 

"  relapsing  fever 258-260 

' '  scarlet  fever 308-31 1 

' '  simple  intermittent  fever 120 

"  "      remittent  fever 134-136 

"  smaU-pox 273-275 

"  typhoid  fever 20-26 

"  typho-malarial  fever 186 

"  typhus  fever 211-216 

"  yellow  fever •  •  88-93 

Fevers,  classification  of 5-7 

' '       contagious 5 

"      dengue 169-173 


INDEX.  ''^^ 

■■Aiii: 

....        5 
Fevers,  endLinic ^ 

"       epidomio .    ^ 

1  -O 
"       introduction  to 

"  ""^''^7^ ;;;':m-:5ni5 

"       njoasles ^ 

"       niiu.-^nmtic  coutagioua •  •  •       ' 

.,  ...  .\ni--iM 

""^'"'^^ .    14S-ir.H 

"       pcrniciou.s o-,n...'r,7 

"       relapsintr "J^^J^^j 

-       sourlot.  ...^ ••••••    ^,,^_j,4 

"       simi>le  mtormittent ,.,o  .  .a 

.^^      .                                                                                            l.>f5-14o 

«•  "       remvttcnt 

„              „                                                                                                2»iH-302 

"       small-pox ^_^^ 

;;  ^yphoid.     ;. ■::■.:■.;■;  181-202 

"       typho-inalarial 

,.       /    ,  20.)-2.»a 

*^'V^^ 85-107 

"     yellow 2^, 

Fresh  air  in  the  treatment  of  typhus  fever 

■'Oil 
Gangrene  of  tonsils  in  scarlet  fever i  --  'i  ^C 

Gastro-enteric  variety  of  pernicious  fever I'J'''    ^^ 

Gastro-enteritis  in  chronic  malarial  infection •      '•' 

,  ....  3j3-.3oI> 

German  measles 

Glandular  enlargements  in  typhus  fever 

Glandular  inflammation  in  scarlet  fever 

Headache  in  dengue  fever ' 

...         o  oOO 

"  miliary  fever 

.  .         ,     l.)4 

"  pernicious  lever 

"  scarlet  fever '    "_ 

typhoid  fever ^  -  ^^^ 

"  typhus  fever ~     '     /' 

Heart,  changes  in  the,  in  chronic  malarial  infection 174 

n  "  relapsing  fever *^*" 

4.  "  typhoid  fever ^'  '^ 

n  "  typhomalarial  fever ''  ^ 

.  "07 

II  "  typhus  fever *■"' 

a  »  yellow  fever 80.  H7 

Hemiplegia  in  chronic  malarial  infection '^ 

Hemorrhage  in  chronic  malarial  infection 

»»  pernicious  fever '     ' 

««  typhoid  fever,  from  intestines ., 

.i  "  larvnx • '- 

,.,,,„,"  19:1 

"  typho-malana.  fever 

Hydrate  of  chloral  in  typh.iid  fewr 

"  "  typhus  fever 

87 
Hypertcathesia  in  typhoid  fever 

Hypochondriasia  in  chronic  malarial  infection 


390  INDEX. 

PAGE 

Hypodermic  injections  of  opium  in  pernicious  fever 164-1 G5 

"  "  sulphate  of  quinine  in  pernicious  fever 164-105 

Icteric  variety  of  pernicious  fever 158-159 

Infantile  remittent  fever 141,  143 

Infarctions  in  the  kidneys  in  typhoid  fever 99 

"  "         lungs  in  yellow  fever 87 

"  "         spleen  in  pernicious  fever 151 

Inoculation 293-295 

Intestines,  lesions  of  the,  in  relapsing  fever 257 

"  "  simple  remittent  fever 134 

"  "  typhoid  fever 14-18 

"  "  typho-malcorial  fever 183-185 

"  "  typhus  fever 208 

Intestinal  hemorrhage  in  typhoid  fever 31,  33 

Iodide  of  iron  in  chronic  malarial  infection 179 

Iron  cough  in  measles •. 342 

Jaundice  in  bilious  remittent  fever 141 

"  pernicious  fever 158-159 

"  relapsing  fever 261 

"  yellow  fever 98 

Kidneys,  changes  in  the,  in  chronic  malarial  infection 174 

"  "  pernicious  fever 153 

"  "  relapsing  fever 257 

"  "  scarlet  fever 307 

"  "  typhoid  fever 9 

"  "  typho-malarial  fever 183 

"  *'  typhus  fever 207 

"  "  yellow  fever 87 

Laryngitis,  in  typhoid  fever 11 

''  typhus  fever 330 

Liver,  changes  in  the,  in  chronic  malarial  infection , .   174 

"  "         measles 337 

"  "  pernicious  fever 151 

"  "  relapsing  fever 257 

"  "  scarlet  fever 308 

"  "  simple  remittent  fever 133 

"  "  typhoid  fever 8-9 

"  "  typho-malarial  fever 183 

"  "  typhus  fever 206 

"  "  yellow  fever 85,86 

Lungs,  changes  in  the,  in  ijernicious  fever 152 

"  "  measles 338 

"  "  typhoid  fever 10,11 

"  "  typho-malarial  fever 183 


INDEX.  391 

PAOB 

Lungs,  changes  in  the,  in  typhus  fever "'' 

"  "  yellow  fever "' 

Lymphatic  ghuids,  eulargemcnt  of,  in  douguo  fever HO 

:^Ialarial  fevers,  uitrwluction  to 100-118 

Masked  intermittent  fever '"^ ' 

Measles 

«'    complications  of 

"     differential  diagnosis  of '"**' 

"    etiology  of 3:{9-:m 

"     morbid  anatomy  of :3:57-339 

'»  "  blood  changes ^''' 

"  '»  eruption '^'^ 

"  "  liver ^■^'^ 

n  »«  lungs "^'^^ 

"  ««  skin ^'^^ 

"  "  spleen '^■^' 

"    period  of  incubation **"*" 

•'     prognosis  of 

"    symptoms  of 341-;J48 

"  "  desquamation •'*■' 

"  "  eruption '^'^^ 

■w  "  iron  cough '^'^^ 

»«  •'  irregularities '^"^ 

oil 
"  "  premomtorj- '^'*'^ 

««  "  pulse 343,344 

«»  "  temperature '^^•^'  '^^ 

"  "  tongue '^^^ 

"    treatment  of '^^^'  '^'p 

*'  ''  arrangement  of  sick-room 3ol 

"  "  cold  applications '^'^ 


diet. 


;.")! 


««  "  opium •^•"*"' 

♦  »  "  sponging '^"'^ 

««  <'  stimulants •'•^''  "'••'■^ 

"  ««  sulphate  of  quinine •^■'^ 

««  "  vapor  inhalations •'•'■' 

*«  "  ventilation '^•'' 

Melancholia  in  chronic  malarial  infection ^ '^ 

Meningitis  in  typhus  fever *-'^" 

Mercury  in  the  treatment  of  dengue  fever 1 '  '- 

n  "  simple  remittent  fever 14i> 

"  •«  typho-raalarial  fever 201 

Mesenteric  glands,  changes  in  the,  in  typh(Md  fever 18-20 

i»  "  '•  typho-malarial  fever 1^» 

Miliary  fever 

"  "       complications  of "'"' 

•  '  "      differential  diagnosis  of '^'^•' 


392  IXDEX. 

PAGE 

Miliary  fever,  duration  of 359 

"      etiology  of 358,  359 

"  "       morbid  anatomy  of 357,358 

"  "      prognosis  of 362 

"  "      relapses  in 361 

"  "       symptoms  of 359-362 

"  "  "  desquamation 3G2 

"  '*  "  eruption 360 

"  "  "  headache 360 

"  "  "  pain,  epigastric 360 

"  "  "  "    precordial 360 

"  "  "  pulse 360 

"  "  "  rapid  respiration 360 

"  "  "  stages 359 

"  *'  "  temperature 360 

"  "  urine 361 

"  "  "  vomiting 361 

''  "      treatment  of 362,  363 

Morbid  anatomy  of,  chronic  malarial  infection 174 

"  "  dengue  fever 169 

"  "  epidemic  roseola 353 

"  "  measles 337-339 

"  "  miliary  fever 357 

"  "  pernicious  fever 149-152 

"  "  relapsing  fever 256-258 

"  "  scarletfever 305-308 

"  "  simple  intermittent  fever 119 

"  "  simple  remittent  fever 132-134 

"  small-pox 269-273 

"  '«  typhoid  fever 7-21 

"  "  typho-malarial  fever 182-186 

"  "  typhusfever 205-211 

"  "  yeUow  fever 85-88 

Morphine,  hypodermic  injections  of,  in  pernicious  fever 164,  165 

"  "  "  simple  remittent  fever 148 

"  "  "  typhoid  fever 79 

Mucous  membrane,  changes  in  the,  in  relapsing  fever 287 

'•  "  "  scarletfever 306 

"  "  "  yellow  fever 86 

Muscles,  changes  in  the,  in  simple  remittent  fever 134 

"  "  "         tyiihoid  fever 12,13 

"  "  "  typhusfever 211 

*'        paralysis  of,  in  typhoid  fever 36 

"  "  typhusfever 223 

Neuralgia,  in  chronic  malarial  infection 176 

Opium  in  the  treatment  of  measles ;^1 


INDEX.  39:i 


TAOE 


Opium  ill  the  treatment  of  pernicious  fever •'''^ 

"  "  nimplo  remittent  fever l'--'7 

•'  "  typhoid  fever 77-71),  H2 

««  "  typho-malarial  fever 2'^0 

««  "  typhus  fever '-•'•* 

Pain  in  the  epigastrium  in  simple  remittent  fever '•' ' 

Parenchymatous  de-jencrations  lu  typhus  fever 2(H> 

Period  of  incubation  in  dengue  fever ^  •*' 

"  ♦'  measles ■'■' 

"  "  scarlet  fever •"  * 

'•  "  email-pox "-"' 

typhus  fever -'•' 

Pernicious  fever '"*  ' 

"  definition  of '"'"^ 

"  dilferential  diagnosis  of l.)9-lti"<. 

"  etiology  of ''*^ 

"  morbid  anatomy  of ^  l!)-l)v 

•  '  "  blood  changes 1  '!• 

«»  "  brain ^"'^ 

«*  "  kidneys l''~ 

t<  "  liver 1"*^ 

»  "  lungs 1  ''2 

a  "  spinal  cord l'*l 

««  "  spleen 1">1 

"  prognosis  of ^^'■^'  ^'''^ 

"  symptoms  of    1.)~-1.j!) 

"  "  algid  variety li»7,  l-'''^ 

"  "  colliquative  variety l-^S 

*»  "  comatose  "       ^•''•^ 

"  "  delirious  "       1">  •,  !•'>•"> 

"  "  gastro-enteric   "       l."),  ITdj 

»»  "  icteric  "       loM-l.V.) 

*«  "  premonitory 1'- 

"  treatment  of ir,:j-l(;,S 

«'  "  bleeding 1'"'  ^ 

"  "  cathartics '•" 

"  «'  depletion l*'^ 

'•  treatment  of,  emetics 1*'1>  l'"'-* 

it  "                 hypodermic  injections  of  opium  and  ipiin- 

ine   I'Jt-l';^ 

"  "  opium ^''* 

«t  ««  stimulants "•' 

«*  "  sulphate  of  quinine ^''* 

♦  t  "  Warl)erg's  tincture '*'''» 

.     •        «  111 

"  varieties  of 

Phlegmasia  dolcns  in  typhus  fever -| 

Phosphorus       '"  "         "'' 


394  INDEX. 

PAGE 

Photophobia  in  relapsing  fever 2G1 

Physiognomy  in  dengue  fever 170 

"  pernicious  fever 158 

"  small-pox 276 

"  typhoid  fever  29,  30 

Premonitory  symptoms  in  measles 341 

"  pernicious  fever 152 

"  scarlet  fever 311-312 

' '  simple  remittent 136 

"  small  pox 275 

"  typhoid  fever 27 

"  typho- malarial  fever 187 

"  typhus  fever 217 

"  yellow  fever 93 

Prognosis  in  chronic  malarial  infection 178 

dengue  fever 172 

epidemic  roseola 355 

measles 349 

miliary  fever 362 

pernicious  fever 162,  163 

relapsing  fever 265 

scarlet  fever 328-330 

simple  intermittent  fever 126 

simple  remittent  fever 143-144 

small-ix)x 286-288 

typhoid  fever 50-60 

typho-malarial  fever 196-198 

typhus  fever , 239-243 

yellow  fever 102 

Pulse  in  dengue  fever 170 

measles 343-344 

miliary  fever 368 

pernicious  fever •. 153-159 

relapsing  fever 261 

scarlet  fever 311,  316 

simple  remittent  fever 137 

small-pox 276 

typhoid  fever 40-42 

typho-malarial  fever 189-191 

typhus  fever 219-223 

yellow  fever 95 

Relapses  in  miliary  fever 362 

"  relapsing  fever 262 

' '  typhoid  fever 58-60 

''  typhus  fever 232 

Relapsing  fever 256-267 

"  comijlications  of 264 


I^'DEX. 


I-AIIE 

...  '-2t;4 

2.')S-2t50 


no5 

Relapsing  fover,  differential  (li!igna><iM  of 

etiology  of or»_.>53 

"  morbid  anatomy  of *"'     "'' 

u  •'  blo.Kl -"'^ 

«<  "  heart -'" 

o-,7 
I.  '•  mtestines ~    ' 

»»  "  kidneys 

liver fy 

tt  "  mucous  membrane *"' ' 

»«  "  spleen " 

.       ,  2<;5 

' '  projmosia  of 

.           f                                                                     ....260-2(3-1 
"  symptoms  or 

"  "  arthritic  pains "*'■ 

Til 
"  "  delirium ~"^ 

'Til 
««  "  diarrhcea ~"'- 

'Vil 
n  "  eruption " 

o(;i 
»«  "  jaundice " 

'«  "  photophobia -^'■ 

"  "  pulse ~**^ 

oi;i 

"  "  temperature ""'^ 

.  .  Til 

"  "  vomiting -"^ 

"  treatment  of 

Respiration  in  typhus  fever 

Salivarj'  glands,  cfhanges  in  the,  in  typhoid  fever on*.  qo« 

_,,^.  304— O'J'i 

Scarlet  fever 

"  complications  of 

,  ^   .^.        f  304 

»'  dehuition  or 

"  differential  diagnosis  of o-o-o-o 

,.  ,  ,  308-311 

"  etiology  of 

«•  morbid  anatomy  of 305-308 

u  "  brain ^^^ 

»i  "  diphtheria ^^^ 

ear =^07 

((  "  gangrene  of  tonsils 30f> 

<(  "  glandular  intlamination -^O'l 

u  «'  kidneys ^^^ 

ti  "  liver •^'^ 

((  »«  mucous  merabranea '^00 

"  skin i^Oo 

"  period  of  incubation _    ^ 

» «  periods  of 

,,  :    ,,f  32M-:W0 

"  protmosis  of 

,,                \                                                                            323-325 

"  sequela; 

'                ,                                                            311-326 

"          symptoms  of _    _ 

»4  "  con\'ul.'<ions '^''* 

41  "  delirium ^'';^ 

t«  "  eruption ^^'^ 


396 


INDEX. 


Scarlet  fever,  symptoms  of,  headache 315 

premonitory 311,  312 

pulse 311,  316 

stages 313 

temperature 311,  316 

tongue 313 

urine 313 

vomiting 311 

treatment  of 330-336 

Sewer  gas,  as  a  cause  of  typho-malarial  fever 13 

Sight,  as  a  symptom  in  typhoid  fever 37 

Simple  intermittent  fever 11 9-144 

etiology  of 130 

differential  diagnosis  of 125 

morbid  anatomy  of 119 

prognosis  of    126 

symptoms  of 120-125 

"  nausea 133 

skin 132 

"  temperature 122,  124 

"  tongue 123 

"  urine 133,  133 

"  vomiting 133 

treatment  of 126-130 

"  iron 130 

"  opium 137 

"  sulphate  of  quinine 128 

' '  stimulants 130 

Simple  remittent  fever 132-148 

"  differential  diagnosis  of 142-143 

"  etiology  of 134-136 

"  morbid  anatomy  of 132-134 

"  "  blood  changes 132 

"  "  intestines 134 

"  "  liver 133 

"  "  muscles 134 

"  "  spleen 133 

"  "  stomach 134 

"  prognosis  of 143, 144 

"  symptoms  of 136-142 

"  "  pain  in  epigastrium 137 

"  "  premonitory 136 

"  pulse 137 

"  "  temperature 137 

"  "  vomiting 137,138 

"  treatment  of 145-148 

"  "  antiphlogistics 145 

"  "  antipyretics 146-148 


i.\i>i;x. 


;{07 


Simple  remittent  fever,  treatment  of,  arrangomont  of  sick-rnum Mtl 

*'  "  cold 14H 

«»  "  mercury 1'*'^ 

««  "  moriihino 14H 

"  "  sulphate  of  quinine 1  "5 

Skin,  appearance  of,  in  dontruc  fever 1»>1)-1  <() 

"  measles •""- 

"  miliary  fever '^^^ 

"  pernicious  fever ir),{-l.)7 

«'  relapsing  fever "''^ 

♦'  scarlet  fever '*"■* 

"  simple  intermittent  fever 1-* 

"  simple  remittent  fever I'll 

"  small-pox -'''   ~^ 

««  typhoid  fever •*-'  -^^ 

«'  typho-malarial  fever '^'^ 

*'  typhus  fever ~ '  •''-"' 

"  yellow  fever '^ 

„      ,,    „  2G8-303 

Small-pox 

«'  complications  of 

"  differential  diagnosis  of ~i^  '^' 

eruption  of 270-273 

"  etiology  of "''^  -"^ 

' '  inoculation  m *" 

"  morbid  anatomy  or ~  ' 

071; 
"  period  of  incubation  of *"  "■' 

,,  ■     f  2sr.-2.s8 

"  procrnosis  ot 

"  symptoms  of "^ 

"  "  convulsions *' 

•t  "  delirium ^~'' 

«»  "  eruption -.n-^ 

«t  "  pain  in  the  back  and  head ~ ' " 

.  07'; 

«  "  phvaiognomv ~ 

«*  "  premonitory ~^ ' 

*«  "  pulse ~'* 

«»  "  skin -i(--.-*4 

*»  "  temperature ~"* 

<■'■  "  vomitmg *■ ' 

"  treatment  of '"  "  -  " 

.      ..  2!»."i-;j(Kl 

' '  vaccination 

Somnolence  in  typhoid  fever ' "' 

"              typhus  fever -" 

Spleen,  changes  in  the,  in  chronic  malarial  infection l '  * 

•'                      measles ' 

»«                      pfrnicious  fever '■" 

«•                      relapsing  fever "^  ' 

«»                      simple  remittent  fever l-*^*' 

"                    typhoid  fever ^ 


898  rNDEX. 

PAGE 

Spleen,  changes  in  the,  in  typho-malarial  fever 183 

"  typhus  fever 206 

"  yellow  fever 88 

Spontaneous  origin  of  typhoid  fever 21 

Stimulants  in  measles 352 

"  pernicious  fever 167 

"  typhoid  fever 73,  74 

' '  typho-malarial  fever 200 

' '  typhus  fever 250-252 

Stomach,  changes  in  the,  in  simple  remittent  fever 134 

"  typhoid  fever 13 

Sulphate  of  quinine  in  chronic  malarial  infection ISO 

"  "  "  dengue  fever 173 

"  "  "  measles 351 

"  "  "  pernicious  fever 164,  165 

"  "  "  simple  intermittent  fever 128 

"  "  "  simple  remittent  fever 146 

"  "  "  typhoid  fever 71-73 

"  "  "  typho-malarial  fever 1 98,  199 

"  "  "  typhus  fever 248 

Suppression  of  urine  in  yellow  fever 97 

Symptoms  of,  chronic  malarial  infection , 174-177 

"  dengue  fever 170-172 

"  epidemic  roseola 355,  356 

"  measles 341-348 

"  miliary  fever 359-362 

'•  pernicious  fever 152-159 

"  relapsing  fever 260-264 

"  scarlet  fever 311-326 

"  simple  intermittent  fever 120-125 

"  simple  remittent  fever 136-142 

"  small-pox    275-284 

"  typhoid  fever 27-45 

"  typho-malarial  fever 187-194 

"  typhus  fever 217-229 

"  yellow  fever 93-100 

Tetanus  in  pernicious  fever 155 

Temperature  in  dengue  fever 170 

' '  measles ....   343 

'♦  miliary  fever 360 

"  pernicious  fever,  algid  variety 157 

"  "  colliquative  variety 158 

"  "  comatose  "       153 

"  "  delirious  "       155 

"  "  gastro-enteric  "       156 

"  "  icteric  "       159 

*'  relapsing  fever 261 


FM»i:\'.  309 

Tcmpemturo  in  scarlet  fever :tl  1 ,  JIKJ 

"  simple  intermittent  fever l'^"J.  1-1 

"  eiinplo  remittent  fever 1-17 

* '  smallpox 'iir, 

"  typhoid  fever :«•,  40 

"  typbo-malarial  fever IW,  I'lO 

"  tyi.lmfl  fever :!1H,  '-.".':{ 

yellow  fever 'S.\  dl 

Tents  in  the  treatment  of  tyi>hns  fever ~  11' 

Thrombi  in  the  heart  in  typlioiil  fever 10 

"  veins  in  typhoid  fever 207 

Tongue,  appearance  of,  in  dengne  fever 171 

"  "  measles '^44 

"  "  pemicions  fever l'>7 

"■  "  scarlet  fever '512 

"  "  simple  intermittent  fever 123 

"  "  typhoid  fever -50 

««  "  typho-malarial  fever 1><^,  101 

"  "  typhus  fever 21H 

"  "  yellow  fever -'O 

Tracheotomy  in  the  treatment  of  typhoid  fever ^0 

Treatment  of  chronic  malarial  infection 1 7'.>.  1  sO 

"  dengue  fever 1  (J  1  i^J 

"  epidemic  roseola •^•*'' 

•'  measles ;}50-:r)2 

"  miliary  fever •^"2,  '503 

"  pemicions  fever KJM-ltJS 

"  relapsing  fever 2111! 

•'  scarlet  fever :{:}0-:};{<> 

"  simple  intermittent  fever 12()-i:?0 

*'  simple  remittent  fever Mo-HH 

smail-pox 2M!»-21)2 

♦♦  typhoid  fever •'1-H4 

*'  typho  malarial  fever lN!)-'202 

"  typhus  fever 2  \:\'2r>r, 

"  yellow  fever 10.{-10<5 

Turpentine  in  the  treatment  of  typhoid  fever  78 

"  "  "  typho-malarial  fever 201 

Tympanitis  in  typhoid  fever '^'5 

Typhoid  fever "-'^* 

"  differential  diagnosis  of 4')-49 

"  duration  of •'•^ 

•'  etiology  of 20-20 

• '  morbid  anatomy  of 7-20 

"  •'  bl<K)d  changes 7,  S 

«♦  "  brain  and  nervous  system   12 

»*  "  bronchial  tubes 11 

•«  "  heart 9.10 


400  INDEX. 

FAOE 

Typhoid  fever,  morbid  anatomy  of  kidneys 9 

"  "  larynx 11,12 

"  «'  liver 8,9 

«*  "  lungs 10,11 

"  '*  intestines 14-18 

"  "  mesenteric  glands 18-20 

"  "  muscles 12,13 

"  ' '  salivary  glands 13 

"  "  spleen 8 

"  "  stomach 12 

"  symptoms  of 27-45 

"  "  abdominal  pain 32,  33 

"  "  convulsions 37 

"  "  delirium 35,36 

"  "  dianhoea 31 

•'  "  emaciation 88 

"  "  epistaxis 37-38 

"  "  eruption 42-43 

"  "  headache 35 

"  "  hearing 37 

"  "  hyperaesthesia 37 

"  "  intestinal  hemorrhage 31-32 

"  "  muscular  paralysis 36 

"  "  physiognomy 29,  30 

"  "  pulse 40-42 

"  "  sight 37 

"  "  somnolence 35 

"  "  taste 37 

"  "  temperature 39-40 

"  "  tongue 30 

■  "  "  tympanitis 33 

"  "  urine 34 

"  prognosis  of 50-60 

"  relapses  in 58-60 

"  treatment  of 61-84 

"  "  alkalies 77 

*'  "  antipyretics 66-73 

"  •         "  arrangement  of  the  sick-room 64 

"  "  astringents 77 

"  "  blood-letting 63 

"  "  cathartics 81 

"  "  cold  applications 67-70 

*'  "  diaphoretics 63 

"  "  diet 75 

"  "  disinfectants 63 

"  "  dry  cups 79 

*•  "  emetics 63 

"  "  hydrate  of  chloral 83 


INDF.X.  401 

I'AOB 

Typhoid  fever,  treatment  of,  miu]>luiio 7y 

"  "  opium 77-H2 

"  "  Btimnlaiits 7;$^  74 

*'  '■  siilplmti- of  qniniiio 71-7:$ 

**  ■  ■  tracheotomy HO 

"  ■■  tnn)cntiiie 7s 

"  "  vapor  iuhahitions 7!l 

Typho-malarial  fever lsl-'2(i'J 

"  definition  of \<^\ 

"  ditforential  diag^nosis  of l!(4-lfl(.» 

"  duration  of ISO 

*'  etiolo{ry  of 18G 

"  morbid  anatomy  of 1  H2_18<J 

"  "  blood  changes 1H2 

"  "  heart ls:j 

"  "  intestines ls:j-ls,") 

"  "  kidneys IS:} 

"  "  liver 1S2 

lun?s ls;j 

"  mesenteric  glands \So 

"  "  spleen ls;{ 

"  prognosis  of liMUIiis 

"  symptoms  of ls7-;r» 4 

"  "  abdomen licj 

"  "  delirium 1!)3 

"  "  diarrhoea 18S-U»1 

"  "  headache V.)2 

"  "  premonitory I,s7 

"  "  pulse ISO,  ini 

'*  "  skin 101 

"  "  temperature 188,  100 

"  "  tongue 188,  101 

"  "  urine 101 

"  treatment  of 108-202 

"  "  calomel 201 

"  "  cold  applications 201 

"  "  diet 202 

"  "  opium 200 

"  "  stimulants 200 

"  sulphate  of  quinine 108 

"  "  turpcntint; 201 

Typhus  fever .  20.')-2ri5 

differential  diagnosis  of 2:12-2.10 

duration  of 232 

•  tiology  of 211-210 

morbid  anatomy  of 20.')-21 1 

"  bloo<l  changes 20fl 

"  brain 207-208 


402 


INDEX. 


Typhus  fever,  morbid  anatomy  of  bronchi 209 

"  "  glandular  enlargements 210 

"  "  heart 207 

"  •'  intestines 208 

"  "  kidneys 207 

"  "  liver 20G 

"  "  lungs 207 

"  "  muscles 211 

"  "  parenchymatous  degenerations 20G 

"  "  phlegmasia  dolens 210 

•'  "  spleen 206 

"  "  thrombi 207 

' '        prognosis  of 239-24:'3 

"         symptoms  of 217-229 

"  "  bronchitis 230 

"  "  coma  vigil 220 

"  "  delirium 220,  222 

"  "  eruption 219,  225 

"  "  headache 217,  222 

"  "  laryngitis 230 

"  "  meningitis , 230 

"  "  muscles 222 

"  "  premonitory 217 

"  "  pulse 219,  224 

"  "  respiration 226 

"  "  somnolence  222 

"  "  temperature 218,  223 

"  "  tongue 218 

' '  "  urine 227 

' '  treatment  of 243,  255 

"  "  cold  applications 249 

"  "  diet 254 

"  "  digitalis 253 

"  "  fresh  air 247 

"  "  hydrate  of  chloral 253 

"  "  opium 253 

"  "  phosphorus 253 

"  "  prophylactic 244-246 

"  "  stimulants 250-252 

"  "  sulphate  of  quinine 248 

"  "  tents 247 

"  "  valerian 253 


Urine,  changes  in  the,  in  miliary  fever 861 

"  "  scarlet  fever 312 

"  "  simple  intermittent  fever 122,  123 

"  "  typhoid  fever 34 

"  "  typho-malarial  fever 191 


I.NDKX.  •!"•'' 


PAOK 

o.>7 


J 

]oo-;{02 


Urine,  clianges  in  tlie,  in  tyithus  fivtr 

•'  "  yoUtnv  fever ^"i 

Vaocinfition i, J.j-.JOO 

VuUriiin  in  the  treiitnient  of  typhus  fever '■i'>'-' 

Vjijiur  inliahitions  in  the  treatment  «>(  mcnalcs :{•>- 

typhoid  fever 

Vari<.l..i.l 

Vomitinjr  in  miliary  fever •'"^ 

pernicious  fever l-'U  1'*!' 

"  relapsing  fever 2(51 

"  scarlet  fever •' '  ^ 

"  simple  intermittent  fever !-■• 

"  "       remittent  fever '•'' 

!sniall-pox ~''"' 

**  yellow  fever •"' 

Wurbery's  tincture,  formula  for 1'''^ 

Yellow  fever 8.")-10ri 

'•  definition  of ^^ 

"  differential  diagnosis  of l'"l 

"  etiolof^y  of H8-9:t 

"  morbid  anatomy  of 80-^ 

blood  changes B8 

"  "  brain ^"t 

"  •«  heart 8f!.  ST 

"  "  kidneys ST 

"  "  liver ■"^•'' 

"  "  lungs sT 

"  "  mucous  membrane S(; 

"  "  skin ^^ 

««  "  spleen    8s 

"  symptoms  of ilo-lOO 

"  "  black  vomit '•"> 

««  "  delirium W 

«*  "  jaundice OS 

'*  "  pulse y"» 

"  "  temperature 5»:5,  !)l 

"  "  tongue i"' 

"  "  urine -'T 

*'  "  voniitiiiLT !•(> 

prognosis  of If- 

treatment  of 1(i.'.-Hm; 


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